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Latino 
Mental 



Current Research 

and 
Policy Perspectives 



EDITORS: 



Cynthia Telles, Ph.D. 
and Marvin Karno. M.D. 



M+^^D247A 



Latino 
Mental 
Health: 



Current Research 

and 
Policy Perspectives 

Offic iinority Heafth 
Center 
3ox37337 

Wi :on, DC 20013-7337 



EDITORS: 

Cynthia Telles, Ph.D. 
and Marvin Karno, M.D. 



This monograph is comprised of papers resulting from research plan- 
ning workshops on "Mental Disorders in Hispanic Populations" 
sponsored by the National Institute of Mental Health (N.I.M.H.). 
This document was prepared under contract number 94MF04837- 
24D from the N.I.M.H. to the Neuropsychiatric Institute, Univer- 
sity of California, Los Angeles (Cynthia Telles, Ph.D., Principal 
Investigator). Juan Ramos, Ph.D., Associate Director of Preven- 
tion, served as the N.I.M.H. Project Officer. 

The views expressed in this publication are those of the author(s) and 
do not necessarily reflect the official position of N.I.M.H. or any 
other part of the U.S. Department of Health and Human Services. 
All material contained in this monograph, except quoted passages 
from copyrighted sources, is in the public domain and may be 
reproduced without permission of the authors. Citation of source 
is appreciated. 

The Editors: Cynthia Telles, Ph.D. is Director, Spanish Speaking 
Psychosocial Clinic, Neuropsychiatric Institute and Hospital and As- 
sistant Clinical Professor, Department of Psychiatry and Biobe- 
havioral Sciences, University of California, Los Angeles (U.C.L.A.). 
Marvin Karno, M.D. is Professor and Director, Division of Social 
Psychiatry, U.C.L.A. Department of Psychiatry and Biobehavioral 
Sciences. 

1994 



Library of Congress Catalog Card Number: 95-69340 



Preface 



The necessity of defining a comprehensive Latino mental health 
research agenda, which can inform public policy, program planning 
and health care reform, has been articulated repeatedly by experts 
in the field. In an effort to address this need, the National Institute 
of Mental Health funded a series of workshops on "Mental Dis- 
orders among Hispanic Populations" between April, 1990 and 
February, 1994. The general intent of the meetings was to audit re- 
cent and ongoing research on epidemiology, assessment, treatment 
and prevention of mental disorders; to discuss policy implications; 
and to identify salient gaps in knowledge and propose related 
research. 

In order to begin the process, we brought together a group of lead- 
ing researchers and policy makers from throughout the United States 
to report on the "state of the art" in specific areas of Latino men- 
tal health research and to formulate recommendations. This mono- 
graph is a collection of selected reports that were prepared by these 
experts. Although these chapters do not comprise an exhaustive 
review of the literature or reflect a full spectrum of investigations, 
they represent some of the most significant recent research efforts 
and related commentary in this field. 

Part One is devoted to the psychiatric epidemiology of mental dis- 
orders and distress among Latino populations. Karno introduces this 
section with a review of early literature and a report on the most im- 
portant prevalence data to date on diagnosable mental disorders 
among Mexican Americans. Roberts reviews the limited epidemio- 
logic data on mental disorders among Hispanic origin children and 
adolescents and reports preliminary data from a National Institute 
of Drug Abuse sponsored study of youth, which provides important 
evidence regarding gender and ethnicity as risk factors for self- 
reported symptoms of psychological distress. Most importantly, he 
provides a carefully thought out research strategy for future epide- 
miologic studies of the etiology and outcome of mental disorders 
among youth of Mexican origin. 

Vega and his colleagues describe an exciting, prospective, large- 
scale, longitudinal study in Dade County, Florida, which was de- 
signed to assess the complex relationships between cultural adapta- 



iv Latino Mental Health 



tion and the experience of psychosocial distress, including symptoms 
of behavioral, mental and substance use disorder among early 
adolescents. This methodologic and conceptual overview of their 
own early study and those of others in this area emphasizes the value 
of empirically derived assessment tools for the epidemiologic study 
of adolescent well-being in different cultural settings. 

Telles reports on the relationships between psychiatric symptoms 
and disorder on the one hand, and the factors of immigration and 
socioeconomic status among Hispanics on the other. She cites im- 
portant discrepancies between earlier studies that relied on symptom 
scales that measure distress levels and the ECA study that assessed 
DSM-III defined mental disorders. Her discussion of the epidemio- 
logic data underscores the role of socioeconomic status, immigrant 
status and level of acculturation as very significant and distinctive 
influences upon vulnerabilities to mental disorder and distress. 

Canino reviews the significant epidemiologic studies of psychiatric 
disorder and symptomatology among mainland and island Puerto 
Ricans over the past decade and compares the findings with those 
from similar studies among other ethnic groups. She concludes her 
overview with some specific measures to improve cultural sensitivity 
and relevance in future epidemiologic studies among Hispanic and 
other cultures. 

Briones and colleagues report on a community study of over 800 
residents of El Paso, Texas regarding the relative influences of Anglo 
versus Mexican- American ethnicity and socioeconomic status upon 
the risk of depressive and anxiety symptoms. The importance of 
socioeconomic status and the even greater importance of more 
specific life stressors in predicting symptoms levels leads them to 
strongly recommend a multifactorial approach to both epidemiologic 
research and clinical practice among Mexican American and other 
ethnic groups. 

Part Two focuses on the assessment of mental disorders among 
Latinos. Lopez reviews the literature regarding the role of cultural 
factors in the expression of psychopathology. He makes a strong case 
for the inclusion of direct measures of culture in empirical studies 
of Latinos and discusses implications for assessment and clinical 
practice. Marcos reviews research regarding the adverse effects of 
the language barrier on the assessment of psychopathology. He dis- 
cusses specific dimensions of the psychiatric examination which are 
strongly influenced by limitations in language proficiency. Mezzich 
examines issues pertinent to the diagnoses and assessment of 



Preface 



Hispanics and, more specifically, discusses strategies for enhancing 
the cultural sensitivity of the DSM-IV diagnostic system. 

Fabrega eloquently critiques current Hispanic mental health re- 
search for its excessive reliance on "Establishment Psychiatry" con- 
ceptual frameworks and diagnostic instruments. He argues that the 
concept of Hispanic culture has not been adequately considered and 
integrated into appropriate models of assessment and treatment. He 
offers recommendations for a culturally sensitive research agenda. 

Part Three focuses on prevention and treatment of mental dis- 
orders among Latinos. Munoz presents compelling data to document 
the need for large scale, culturally and linguistically appropriate 
preventive interventions to address the growing mental health needs 
of Hispanic populations. He offers specific suggestions for the im- 
plementation of such programs. Vega and his associates describe the 
results of a large scale, community based preventive intervention 
research project for women of Mexican descent. Their thoughtful 
discussion of the design and implementation of a culturally sensi- 
tive prevention program, as well as the limitations of such an effort, 
provides important insight with implications for future research and 
practice. 

Martinez reviews the treatment research literature pertaining 
to Latinos, highlighting the important efforts, for example, of 
Szapocznik within Cubans and of Constantino and Comas-Diaz with 
Puerto Ricans. He discusses the research challenge of defining and 
investigating culturally sensitive treatment modalities. 

In the final section of this monograph, public mental health ad- 
ministrators provide important commentary on the need for future 
research efforts to more directly inform public policy and program 
planning. Floyd Martinez challenges the research community to 
redirect its efforts and focus on more relevant and critical issues cur- 
rently affecting the management and delivery of mental health care 
for Latinos. Padilla describes a system-wide effort in a public mental 
health department to provide culturally appropriate services to 
Latinos; in this context, she makes the case for more research with 
practical application to the public sector. 

Our hope is that these initial efforts and recommendations will 
provide the impetus for the development of a comprehensive and 
coordinated Latino mental health research agenda. As proposed by 
the experts, this agenda should include the future study of the epi- 
demiology of mental disorders and distress, especially among chil- 
dren; optimal strategies for defining, assessing and diagnosing 



vi Latino Mental Health 



mental disorders; effective and culturally competent treatment mo- 
dalities and preventive interventions; and demonstration projects 
that evaluate and improve the accessibility, delivery and quality of 
treatment. 

The dramatic underutilization of health and mental health services 
by Latino populations and the failure of the existing health care 
delivery systems to provide sufficient and appropriate services have 
been documented extensively by major federally funded investiga- 
tions, including the Epidemiologic Catchment Area Program and 
the Hispanic Health and Nutritional Examination Survey. The 
development of an adequate knowledge base in areas such as 
prevalence, risk factors, high risk groups, barriers to utilization, 
appropriateness of care and cost-effectiveness of interventions, for 
example, is critical, especially at this time of substantial reorgani- 
zation of the structure, management and financing of national and 
local health and mental health care systems. Existing research find- 
ings should be analyzed, and a future research agenda should be de- 
veloped to guide the design of health care reform programs and 
managed care systems that are responsive and responsible. In fact, 
it is essential that standards of care and conditions of participation 
for providers of mental health services to Latinos include the neces- 
sary cultural and linguistic components to ensure accessibility and 
quality of care, as importantly as strategies for cost containment. 

We wish to express our deepest appreciation to Dr. Juan Ramos, 
Associate Director, National Institute of Mental Health, not only 
for his assistance with this monograph, but most importantly for his 
invaluable support, guidance and advocacy on behalf of Latino men- 
tal health research. It would be almost impossible to identify a lead- 
ing figure in this field who has not benefitted, directly or indirectly, 
from his tireless efforts over the course of almost three decades. 
Lastly, the secretarial and administrative assistance of Lina Alva- 
rez and Nancy Smith is very much appreciated. 



Cynthia A. Telles 

Marvin Karno 

University of California, Los Angeles 

August, 1994 



List of Authors 



David F. Briones, M.D., FAPA, Professor and Chair, Department 
of Psychiatry, Texas Tech University Health Sciences Center, El 
Paso 

Glorisa Canino, Ph.D., Professor, Department of Psychiatry, 
University of Puerto Rico School of Medicine 

Horacio Fabrega, M.D., Professor, Department of Psychiatry and 
Anthrology, University of Pittsburgh School of Medicine 

Peter Heller, Ph.D., Professor, Department of Sociology, Middle 
Tennessee State University, Murfreesboro, Tennessee 

Marvin Karno, M.D., Professor and Director, Division of Social 
Psychiatry, Department of Psychiatry and Biobehavioral Sciences, 
University of California, Los Angeles 

Steven R. Lopez, Ph.D., Associate Professor, Department of Psy- 
chology, University of California, Los Angeles 

Luis Marcos, M.D., Commissioner, City of New York Health and 
Hospitals Corporation, New York 

Cervando Martinez, M.D., Department of Psychiatry, University 
of Texas Health Sciences Center, San Antonio 

Floyd Martinez, Ph.D., Executive Director, La Frontera Center, 
Tucson, Arizona 

Juan E. Mezzich, M.D., Ph.D., Professor, University of Pittsburgh 
Medical School 

Ricardo F. Munoz, Ph.D., Professor, Department of Psychiatry, 
University of California, San Francisco 

Sandra Padilla, M.A., Deputy to the Commissioner, New York State 
Office of Mental Health, Albany, New York 

Robert E. Roberts, Ph.D., Professor, School of Public Health, 
University of Texas, Houston 

Cynthia A. Telles, Ph.D., Director, Spanish Speaking Psychosocial 
Clinic, Neuropsychiatric Institute and Hospital, Department of 
Psychiatry and Biobehavioral Sciences, University of California, 
Los Angeles 



viii Latino Mental Health 



Ramon Valle, Professor, Department of Social Work, San Diego 
State University 

William Vega, Ph.D., Professor, School of Public Health, Univer- 
sity of California, Berkeley 



Contents 



PREFACE 111 



AUTHORS Vll 



Part One Psychiatric Epidemiology of Mental 

Disorders and Distress 



chapter 1 The Prevalence of Mental Disorders 

among Persons of Mexican Birth or Origin 
Marvin Karno 



chapter 2 Research on the Mental Health of 

Mexican Origin Children and Adolescents 
Robert E. Roberts 



17 



chapter 3 The Role of Cultural Factors in 

Mental Health Problems of 

Hispanics Adolescents 

William A. Vega, Rick Zimmerman. 
George J. Warheit, David Jackson, 
Andres Gill and Jan Sokolkatz 



41 



chapter 4 Hispanic Immigration and 

Socioeconomic Status: A Review of 
Psychiatric Epidemiologic Findings 
Cynthia A. Telles 



63 



Contents 



chapter 5 Psychiatric Conditions among 

Puerto Ricans: Are they More Prevalent 
than in Other Ethnic Groups? 
Glorisa Canino 



73 



chapter 6 Factors Associated with Psychological 
Distress among Mexican-American and 
Anglo Populations Residing in a Border City 
David F. Briones, Peter Heller, 
Salvador Aguirre-Hauchbaum, 
H. Paul Chalfant, Alden Roberts 
and Walter F. Farr 87 



Part Two 



Assessment 



107 



chapter 7 Latinos and the Expression of 
Psychopathology: A Call for the 
Direct Assessment of Cultural Influences 
Steven R. Lopez 



109 



chapter 8 The Psychiatric Examination 
Across The Language Barrier 
Luis Marcos 



129 



chapter 9 Hispanic Mental Health Research. 
A Case for Cultural Psychiatry 
Horacio Fabrega 



139 



chapter 10 DSM-IV Development and 
Hispanic Issues 

Juan E. Mezzich 



171 



Contents 



XI 



Part Three Primary Prevention and treatment 



181 



chapter 11 Toward Combined Prevention and 
Treatment Services for Depression 
Ricardo F. Munoz 



183 



chapter 12 Preventing Depression in 

the Hispanic Community: An Outcome 
Evaluation of Projecto Bienstar 

William A. Vega, Ramon Valle 
and Bohdan Kolody 



201 



chapter 13 Psychiatric Treatment of 

Mexican-Americans: A Review 
Cervando Martinez 



227 



Appendix Commentary on Management of 
Public Sector Mental Health 
Services for Latinos 



241 



Mental Health Research in 

the Public Sector and its Impact on 

Hispanic Clients 

Floyd Martinez 



243 



Systems Change in 
Public Mental Health 
Sandra Padilla 



249 



Part I 



Psychiatric 

Epidemiology of 

Mental Disorders 

and Distress 



The Prevalence of Mental Disorder 
Among Persons of Mexican Birth or Origin 

Marvin Karno, M.D. 



History 

In the late 1950s, the first major report on the prevalence of men- 
tal disorders among a U.S. Hispanic population, viz., Mexican- 
Americans in Texas, disclosed a paradox. The findings of Jaco 
(1959) that Mexican-Americans in Texas had lower rates of treated 
mental disorder than did Anglo-Americans was paradoxical in light 
of the seminal report by Hollingshead et al. (1958) that rates of 
treated mental disorder varied inversely with socioeconomic status 
(SES). The low rate of disorder reported for Mexican-Americans in 
Texas was puzzling in view of the fact that SES levels among the 
Mexican-American population in Texas were substantially lower 
than among the Anglo-American population. Jaco's interpretation 
that this rate of treated illness reflected a true (and impressively low) 
community rate among this population was based on his observa- 
tions of strong extended kin, social and emotional support, resources 
within Mexican-American communities which he regarded as a fac- 
tor protective against the development of mental disorders. 

Fabrega et al. (1968) reported a decade later from Texas that less 
acculturated Mexican-American patients seen in a public outpatient 
clinic displayed more severe symptoms of psychopathology com- 
pared to both more acculturated Mexican-Americans and Anglo- 
Americans. The conclusion was tentatively drawn that high levels 
of family tolerance and support caused longer delays in the seeking 
of professional care, thus engendering higher levels of psychopatho- 
logy by the time of first professional contact. 

This very different interpretation that the Mexican-American fa- 
mily's support function served to contain mental disorder within the 
family environment rather than prevent mental disorder was further 
strengthened by a California study in the 1960s. Karno and Edger- 
ton (1969) confirmed that Mexican-Americans were dramatically 
under-represented in proportion to their population numbers, in 



Latino Mental Health 



both outpatient and inpatient public sector treatment programs in 
California and other southwestern states. They carried out a bilin- 
gual community survey of 444 Mexican- Americans and 224 Anglo- 
Americans household residents in East Los Angeles to determine 
cultural differences in perceptions and definition of and attitudes 
toward mental disorder that might shed light on the paradox of 
under-representation in mental health facilities. Their findings sug- 
gested that, rather than cultural differences, the primary reasons for 
the low prevalence of treated mental disorder in the Mexican- 
American community of East Los Angeles were: (1) the lack of avail- 
able, affordable mental health resources; (2) the barrier of language; 
(3) and the strong reliance upon family physicians as the front-line 
mental health resource. 

Such evidence as that provided by Fabrega and colleagues, Karno 
and Edgerton, and others, however, was indirect only. It was with 
the advent of both an operational diagnostic system (DSM-I11, DSM- 
III-R) that it became possible to plan and carry out the direct mea- 
surement of the prevalence of various mental disorders and reported 
roles of utilization of mental health services in both Euro-American 
and ethnic minority communities in the United States. The impetus 
for such an investigation was provided in 1978 by the Report of the 
President's Commission on Mental Health (Report, 1978), which in- 
cluded a major recommendation for a large-scale community 
epidemiologic study of mental disorders as a first step in the rational 
planning for mental health, services throughout the United States. 

The Epidemiologic Catchment Area Program 

In response to the President's Commission, the National Institute 
of Mental Health, in collaboration with five major universities, spon- 
sored the Epidemiologic Catchment Area (EC A) project, which dur- 
ing the past decade has provided an extraordinarily rich psychiatric 
data base on over 18,500 randomly selected adult household respon- 
dents and over 2,000 institutionalized adult respondents residing in 
five U.S. communities. The first four ECA sites (New Haven, Bal- 
timore, St. Louis, and the Piedmont area of North Carolina) were 
communities that included adequate numbers of Black, elderly and 
rural subjects required by the design of the study. A fifth (and fi- 
nal) site was required to provide the opportunity to assess the preva- 
lence and incidence of selected, DSM-III-defined mental disorders 
and the utilization of treatment resources by a substantial commu- 
nity of Mexican- American respondents. Los Angeles and the UCLA 



The Prevalence of Mental Disorders 



Department of Psychiatry and Biobehavioral Sciences were selected 
in 1980 for this specific epidemiologic task. The importance of this 
decision was represented by 1980 census data indicating that the U.S. 
Hispanic population numbered 14.6 million, about 60% of whom 
were of Mexican origin or birth (Department of the Census, 1981). 
The largest concentration of Mexican-Americans resided in the 
greater Los Angeles Area. 

The methods and results of the entire five-site ECA study are 
reported in detail in two monographs (Eaton & Kessler, 1985; Robins 
& Regier 1991). These are far more convenient and accessible than 
are the hundreds of individual research reports from the ECA study 
scattered throughout various journals over the past 10 years. 

The Los Angeles site of the ECA study (LAECA) comprised two 
NIMH-defined Catchment Areas; one in East Los Angeles was 
predominantly (83%) Hispanic, and the other, at the west end of the 
city adjacent to the Pacific coast, including the communities of 
Venice and Culver City, was only 21 % Hispanic. The two catchment 
areas selected were chosen for the mirror-image proportions of 
Hispanic non-Hispanic population, their near identical total popu- 
lations, and the presence in each of a strong, well established, 
comprehensive Community Mental Health Center. These Centers 
contracted with the LAECA site team to assist with assuring com- 
munity entre, the provision of sites for the testing and refining of 
bilingual instruments and the recruitment of highly motivated inter- 
viewers for the study. 

A two-stage probability sampling design, using census blocks as 
primary sampling units and households as secondary units, resulted 
in the random selection of 3,125 household respondents from the two 
LAECA catchment areas. The NIMH-sponsored Diagnostic Inter- 
view Schedule (DIS) (Robins et al., 1981; Robins et al., 1982; Hel- 
zer et al., 1985), was administered in face-to-face interviews with 
1,243 Mexican-American and 1,309 non-Hispanic white respondents. 
The balance of 573 respondents (18% of the sample) were of diverse 
national and ethnic backgrounds and data concerning them will not 
be reported here except in summary presentations of the entire 
LAECA sample in which they are subsumed. Of the total number 
of Hispanic-Americans interviewed, 87% were of Mexican birth 
or origin. 

A preliminary substantial task of the LAECA site team was the 
creation and testing of a Spanish-language version of the DIS. This 
work demonstrating essential equivalence of the English and Spanish 



Latino Mental Health 



versions is reported elsewhere (Burnam et al., 1983; Karno et al., 
1983). The importance of this work is later demonstrated by the fact 
that among Mexican- American respondents, 47% completed the in- 
terview in Spanish. 

Three areas of special interest, in addition to basic prevalence and 
incidence data, were emphasized in the LAECA study. The richly 
complex processes of adaptation to a new culture and a new nation 
have been a particular focus of scholars and investigators concerned 
with the health and mental health of the U.S. Hispanic origin popu- 
lation. The LAECA site team constructed a 26-item Acculturation 
Scale, based substantially on earlier efforts by Cuellar et al. (1980), 
Szapocznik et al. (1978). The reliability and construct validity of the 
scale are reported elsewhere (Burnam et al., 1987), as is the relation- 
ship of acculturation to the lifetime prevalence of mental disorder 
among LAECA Mexican- American household respondents (Burnam 
et al., 1987). A brief review of the significant findings on the rela- 
tionships discovered between acculturation, migration and rates of 
mental disorder will be presented in this report. 

The LAECA site team received supplemental funding from the 
National Center for the Prevention and Control of Rape to col- 
laboratively develop and include in the survey questionnaire a ser- 
ies of questions pertaining to the respondent's lifetime experience 
with sexual assault, either as child or adult. Some of the results of 
that supplemental study reported elsewhere (Burnam et al., 1988; 
Golding et al., 1988; Golding et al., 1989; Siegel et al., 1987; Siegel 
et al., 1989; Sorenson et al., 1987) will be briefly presented in this 
overview chapter. 

A final major emphasis of the national ECA study was to assess 
the use of a wide range of health-related services by all respondents, 
in order to assist in the rational planning of mental health care. The 
three sectors of care which were inquired after by detailed questions 
in the core interview at each site were as follows: (1) specialty men- 
tal health services, (2) general medical resources, and (3) other hu- 
man service resources. The latter included clergy, social and family 
service agencies, spiritualists, and others. Given the paradox dis- 
closed by the work of Jaco over thirty years ago which was cited at 
the beginning of this chapter, the issue of utilization of services was 
considered to be of special importance at the LAECA site. 

There was at last the opportunity to determine if Mexican- 
Americans did or did not use mental health services proportional to 
the non-Hispanic white community. Some of the data from reports 



The Prevalence of Mental Disorders 



(Hough et al., 1987; Wells etal., 1987; Wells et al., 1988; Wells et 
al., 1989) on this aspect of the LAECA project will also be briefly 
summarized. 

Results From The LAECA Study 

Lifetime Prevalence Rates 

Table 1 reveals that the overall rate for any DIS disorder is almost 
identical for non-Hispanic whites, Mexican- Americans, and the total 

Table 1. Lifetime Prevalence of DIS/DSM-III Disorders* 







LOS ANGELES 






Non-Hispanic 


Mexican 


Total 




Whites 


Americans 


Persons 




(N = 


1243) 


(N = 


1309) 


(N = 3125) 


Substance Use Disorders 


22.0 


(1.2) 


18.4 


(1.2) 


18.5 (0.7) 


Alcohol Use/Dependence 


14.8 


(1.1) 


17.3 


(1.2) 


14.9 (0.7) 


Drug Abuse/Dependence 


13.2 


(0.9) 


3.7 


(0.4) 


7.3 (0.5) 


Schizophrenia/iform 


0.9 


(0.3) 


0.5 


(0.2) 


0.7 (0.2) 


Schizophrenia 


0.8 


(0.3) 


0.4 


(0.2) 


0.6 (0.2) 


Schizophreniform 


0.1 


(0.1) 


0.1 


(0.1) 


0.1 (0.0) 


Affective Disorders 


11.0 


(1.6) 


7.8 


(0.9) 


8.9 (0.6) 


Manic Episode 


1.0 


(0.3) 


0.3 


(0.2) 


0.5 (0.1) 


Major Depressive Episode 


8.4 


(0.8) 


4.9 


(0.7) 


6.4 (0.5) 


Dysthymia 


4.1 


(0.6) 


4.8 


(0.8) 


4.2 (0.4) 


Anxiety Disorder 


13.6 


(1.2) 


14.5 


(1.1) 


13.5 (0.7) 


Phobia 


10.7 


(1-0) 


13.5 


(1.2) 


11.7 (0.6) 


Panic Disorder 


1.8 


(0.4) 


1.2 


(0.3) 


1.5 (0.3) 


Obsessive-Compulsive Disorder 


3.0 


(0.5) 


1.8 


(0.4) 


2.1 (0.3) 


Antisocial Personality Disorders 


3.0 


(0.5) 


3.6 


(0.5) 


2.9 (0.3) 


Any DIS Disorder! 


35.2 


(1.7) 


34.6 


(1.4) 


33.2 (1.0) 



DIS indicates Diagnostic Interview Schedule; ECA, Epidemiologic Catchment 
Area. Numbers in Parentheses are standard errors. 

tlncludes cognitive impairment, anorexia nervosa and somatization disorder. 

Adapted from Karno M, Hough RL, Burnam MA, et al. Lifetime prevalence of 
specified psychiatric disorders among Mexican Americans and non-Hispanic Whites 
in Los Angeles. Arch Gen Psychiatry 1987; 44:696. 

*Taken from: Gaviria M, Arana JD, eds. Health and behavior: Research agenda 
for Hispanics. The Simon Bolivar Research Monograph Series No. 1. Chicago: 
University of Illinois Press, 1987. All material in this volume is in the public do- 
main. The data is from investigations supported by NIMH-UCLA cooperative 
Agreement U01 MH 35865 and NIMH RSDA Award MH 00351. 



Latino Mental Health 



LAECA sample. There are only two notable specific exceptions; 
drug abuse/dependence is more than three times as prevalent among 
non-Hispanic whites compared to Mexican- Americans, and major 
depressive disorder is also more prevalent among non-Hispanic 
whites. The high rate of drug abuse among non-Hispanic whites is 
among men and women, while the discrepancy in rates for major 
depression is due to the very high rate of the disorder afflicting non- 
Hispanic white women. Indeed, non-Hispanic white women between 
the ages of 18 and 39 reported a lifetime prevalence rate greater than 
15% for major depression. This was two and a half times the rate 
for Mexican-American women of the same age range. 

Detailed analyses of the LAECA lifetime rates are found in Karno 
et al. (1987), and six-month prevalence rates will be found in Bur- 
nam et al. (1987). The lifetime rates for any DIS disorder were gener- 
ally comparable, at all five ECA sites, with somewhat higher rates 
at the Baltimore and North Carolina sites due to the unusually high 
rates of anxiety (particularly phobic) disorders reported from those 
two sites. The Los Angeles total rates for both non-Hispanic whites 
and Mexican-Americans were in about the mid-range compared to 
the other sites. 

Acculturation and Immigrant Status 

Eight major DIS-DSM-III disorders (major depression, dys- 
thymia, phobia, obsessive compulsive disorder, panic disorder, 
alcohol abuse/dependence, drug abuse/dependence, and anti-social 
personality) were assessed according to levels of acculturation and 
country of birth, viz. , U.S. or Mexico, among the Mexican- Ameri- 
can respondents. Initial analyses revealed that native-born Mexican- 
Americans who were characterized by high levels of acculturation 
reported higher lifetime prevalence rates of major depression, dys- 
thymia, phobia, alcohol abuse/dependence and drug abuse/depen- 
dence compared to immigrant Mexican- Americans. However, after 
controlling for country of birth and other demographic factors, only 
a single difference was found in those of high versus low accultu- 
ration. Immigrants characterized by high acculturation reported 
marginally more prevalent drug abuse/dependence than those of low 
acculturation. Among U.S. -born Mexican-Americans, level of ac- 
culturation was unrelated to the prevalence rate of any of the eight 
disorders examined. 

Country of origin and ethnicity influenced the lifetime prevalence 
rate of three out of six DSM-III defined anxiety disorders. Simple 



The Prevalence of Mental Disorders 



phobia was more prevalent among U.S. -born Mexican-Americans 
compared to immigrants and native non-Hispanic whites. U.S. -born 
Mexican- Americans also report higher rates of agoraphobia than im- 
migrant Mexican- Americans. In regard to generalized anxiety dis- 
order (not included in the DIS but independently included at the 
LAECA site), native-born non-Hispanic whites reported higher life- 
time levels than either immigrant or native Mexican- Americans. 
Refer to Karno et al. (1987) for detailed analyses and discussion of 
anxiety disorders assessed by the LAECA site. 

Sexual Assault 

The basic question asked of all LAECA respondents concerning 
sexual assault was: "In your lifetime has anyone ever tried to pres- 
sure you or force you to have sexual contact? By sexual contact I 
mean their touching your sexual parts, your touching their sexual 
parts, or sexual intercourse?" Of the total LAECA sample (46% 
Hispanic, 42% non-Hispanic white, 47% male and 53% female), 
5.3% reported sexual assault during childhood. Non-Hispanic whites 
reported higher rates than Hispanics (8.7% vs. 3.0%) and women 
reported higher rates than men (6.8% vs. 3.8%). Sexual assault dur- 
ing adult life, i.e., at or after age 16, was reported by 10.5% of the 
total sample. 

Mexican-Americans reported less than half as much adult sexual 
as assault non-Hispanic whites (6.8% vs. 15.5%), and the highest 
rate (26.3%) was reported by non-Hispanic white women ages 18- 
39. The sources cited (Burnam et al., 1988; Golding et al., 1988; 
Golding et al., 1989; Siegel et al., 1987; Siegel et al., 1989; Soren- 
son et al., 1987) should be consulted for detailed analyses and dis- 
cussion. Of relevance here is that childhood sexual assault was most 
often by an acquaintance, carried out by persuasion rather than 
threat or physical aggression, and usually occurred about the age of 
10. In contrast, in reporting on their most recent adult sexual assault 
experiences, over half of the respondents who had been assaulted ex- 
perienced harm or the threat of harm, despite the fact that in three 
quarters of the instances the victims were acquainted with their as- 
saulters. A history of sexual assault was also found to predict the 
later onset of anxiety disorders, major depressive episodes, and 
alcohol or drug abuse or dependence. Childhood sexual assault 
was found to be more strongly predictive of these later mental dis- 
orders than was sexual assault experienced in adulthood (Burnam 
etal., 1988). 



10 



Latino Mental Health 



Utilization 

The utilization of mental health services was the issue with which 
this chapter's historical review began, and it was also the issue which 
was the stimulus and focus of much of the research concerning 
Hispanic mental health in the United States in the 1960s and 1970s. 
Some basic LAECA utilization data is summarized in Table 2 and 
Table 3, respectively, although detailed additional data will be found 
in the sources cited (Hough et al., 1987; Wells et al., 1987; Wells et 
al., 1988; Wells et al., 1989). 

The summary tabular data presented here indicates that Mexican- 
Americans with a DIS/DSM-III mental disorder within the six 
months prior to interview made significantly fewer visits to general 
health or mental health resources than did non-Hispanic whites. Los 
Angeles non-Hispanic white utilization rates are essentially the same 
as utilization rates at the other four EC A sites. This means that, as 
originally observed thirty years ago, the utilization of mental health 
services by Mexican- Americans is distinctively low. 



Table 2. Utilization of Ambulatory Care' 









LOS ANGELES 






Mexican 


Non-H 


ispanic 


Total 




Americans 


Whites 


Persons 


All Persons 












Health and/or mental 












health visits 


39.4 


(1.8) 


58.0 


(1.6) 


48.1 (1.1) 


Average number of visits 












per person 


2.03 


(0.2) 


3.53 


(0.2) 


2.75 (0.2) 


Persons with any Recent 












DIS/DSM-III Disorder 












Health and/or mental 












health visits 


48.4 


(4.2) 


70.6 


(3.7) 


56.5 (2.5) 


Average number of visits 












per person 


3.10 


(0.6) 


6.61 


(0.8) 


4.49 (0.5) 



Adapted from Hough RL, Landsverk JA, Karno M, et al. Utilization of health and 
mental health services by Los Angeles Mexican Americans and non-Hispanic 
Whites. Arch Gen Psychiatry 1987; 44:704. 

*Taken from: Gaviria M, Arana JD, eds. Health and behavior: Research agenda 
for Hispanics. The Simon Bolivar Research Monograph Series No. 1. Chicago: 
University of Illinois Press, 1987. All material in this volume is in the public do- 
main. The data is from investigations supported by NIMH-UCLA cooperative 
Agreement U01 MH 35865 and NIMH RSDA Award MH 00351. 



The Prevalence of Mental Disorders 



11 



Table 3. Percent with Mental Health Visits in Past Six Months by 
Type of Provider Seen and DIS/DSM-III Disorder Status* 









LOS ANGELES 








Mexican 
Americans 


Non-Hispanic 
Whites 


Total 
Persons 


All Persons 














Mental health visits (total) 
General medical provider only 
Mental health specialist 


4.5 
2.0 

2.4 


(0.7) 
(0.4) 
(0.5) 


9.0 
1.9 
7.0 


(0.7) 
(0.4) 
(0.5) 


6.2 
1.9 

4.4 


(0.5) 
(0.2) 
(0.3) 


Persons with recent 
DIS/DSM-III disorder 














Mental health visits (total) 
General medical provider only 
Mental health specialist 


11.1 

2.7 
8.4 


(2.7) 
(1.2) 
(2.0) 


21.6 

4.9 

16.8 


(2.4) 
(1.0) 
(2.1) 


14.4 

3.4 

11.0 


(1.5) 
(0.7) 
(1.3) 


Persons with past 
DIS/DSM-III disorder 














Mental health visits (total) 
General medical provider only 
Mental health specialist 


4.4 
3.1 
1.3 


(1.6) 
(1.5) 
(0.5) 


10.1 
3.0 

7.2 


(2.1) 
(1.5) 
(1.6) 


7.2 
3.1 
4.1 


(1.2) 
(1.0) 

(0.8) 


Persons with no lifetime 
DIS/DSM-III disorder 














Mental Health visits (total) 
General medical provider only 
Mental health specialist 


2.5 
1.6 
0.9 


(0.5) 
(0.3) 
(0.4) 


5.2 
0.8 
4.4 


(0.8) 
(0.3) 
(0.6) 


3.7 
1.2 
2.6 


(0.5) 
(0.2) 
(0.4) 



Adapted from Hough RL, Landsverk JA, Karno M, et al. Utilization of health and 
mental health services by Los Angeles Mexican Americans and non-Hispanic 
Whites. Arch Gen Psychiatry 1987; 44:704. 

*Taken from: Gaviria M, Arana JD, eds. Health and behavior: Research agenda 
for Hispanics. The Simon Bolivar Research Monograph Series No. 1. Chicago: 
University of Illinois Press, 1987. All material in this volume is in the public do- 
main. The data is from investigations supported by NIMH-UCLA cooperative 
Agreement U01 MH 35865 and^NIMH RSDA Award MH 00351. 



In contrast, Mexican- Americans with or without a current or past 
mental disorder made use of the general medical care sector to the 
same degree as non-Hispanic whites. Among LAECA respondents, 
non-Hispanic whites made use of the specialty mental health sector 
about five times as frequently as did Mexican-Americans. More 
detailed analyses revealed that less acculturated Mexican- Americans 
made less use of mental health care and general medical resources 
than did the more acculturated. Non-Hispanic whites with a recent 



12 Latino Mental Health 



mental disorder were seven times as likely to use outpatient mental 
health services than similarly afflicted but less acculturated Mexican- 
Americans. Those respondents who had experienced sexual assault 
were more likely to consult medical providers and those assaulted 
during childhood were more frequent users of mental health care 
than those not so victimized. 

Discussion 

The prevalence of mental disorders and utilization of services 
reported by Mexican-Americans in two catchment areas in Los An- 
geles in the 1980s cannot be used as a basis for generalizing to the 
more than 20,000,000 persons of Hispanic birth or origin now resid- 
ing in the U.S. The data presented here, however, does lend support 
to the belief that the major mental disorders defined in DSM-III (and 
refined in DSM-III-R) are, with the exceptions of substance abuse 
and possibly phobic disorders, distributed in the U.S. population 
rather evenly across major ethnic groups. This is consistent with the 
findings of the other four sites, which interviewed substantial num- 
bers of African- Americans, that there were few differences in the 
prevalence rates of mental disorder among African- Americans com- 
pared with either non-Hispanic whites or LAECA site Mexican- 
American sample. 

Although the low rate of utilization of mental health services by 
Mexican- Americans is consistent with earlier observations, the 
primary reason for it appears to be simply that of unavailability of 
such services to large sectors of the U.S. Hispanic origin population. 
Karno & Morales (1971) reported that a fully bilingual mental health 
service, located in the heart of a residential Mexican-American com- 
munity, was very heavily utilized by Hispanic- Americans. The more 
frequent use of mental health services by more acculturated Mexican- 
Americans also suggests that such individuals may have greater ac- 
cess to mental health services and information about such services. 
There still are very few Spanish-speaking mental health professionals 
and, in recent years, fewer mental health services available at low 
cost in Spanish and in locations readily accessible to rapidly growing 
and still generally low-income, Hispanic origin communities in the 
United States. 

Short of a national health care program that would provide low- 
cost mental health care to those at the lower socioeconomic levels, 
and care which is socioculturally informed and sensitive, it is difficult 



The Prevalence of Mental Disorders 1 3 



Table 4. Standardized and Unstandardized Rates of Major Depressive 
Episode. Hispanic HANES and NIMH Epidemiologic 
Catchment Area 





Mexican 


Cuban 


Puerto 




ECA 


Diagnosis 


Americans 8 


Americans 


Ricans 


Hispanics' 


3 5-site Range 


(n) 


(3555) 


(902) 


(1343) 


(1308) 


(17,264) 


Lifetime 


4.2 


3.9 


8.9 


4.6 


4.7-9.8 


(Unstandardized) 




(3.5) 


(9.0) 


(4.9) 


(3.7-8.4) 


Six-month 


2.3 


2.4 


5.8 


2.5 


2.2-4.2 


(Unstandardized) 




(2.2) 


(5.8) 


(2.8) 


(1.7-3.6) 


One-month 


1.8 


1.4 


4.8 


2.1 


1.5-3.2 


(Unstandardized) 




(1.5) 


(4.9) 


(2.4) 


(1.5-2.6) 



a The Mexican American population was used to directly standardize all other rates 
shown. Unstandardized rates appear in parentheses below standardized rates. 

b Los Angeles only. Includes 1,243 Mexican Americans. 

c New Haven, Baltimore, St. Louis, Piedmont (North Carolina) and Los Angeles 
Nonhispanic Whites. 

* Adapted from Moscicki EK, Rae D, Regier DA, Locke BZ. The Hispanic health 
and nutrition examination survey: Depression among Mexican Americans, Cuban 
Americans, and Puerto Ricans. In: Gaviria M, Arana JD, eds. Health and behavior: 
Research agenda for Hispanics. The Simon Bolivar Research Monograph Series No. 
1. Chicago: University of Illinois Press, 1987. All material in this volume is in the 
public domain. The data is from investigations supported by NIMH-UCLA cooper- 
ative Agreement U01 MH 35865 and NIMH RSDA Award MH 00351. 



to envision significant progress in meeting the mental health needs 
of this nation's Hispanic population. 

New Research 

A major epidemiologic study of the prevalence of mental disorders 
among Hispanic children and youth is greatly needed. Such an un- 
dertaking would most profitably be carried out in conjunction within 
a multi-site collaborative structure like that of the ECA study. Such 
a study should target risk factors of special significance to Hispanic 
children and their families, such as refugee/immigrant life ex- 
perience, exposure to urban gang activities, violence, and other con- 
ditions of poverty and discrimination. Such a study could provide 
important comparative data to that obtained on childhood mental 
disorders and stresses experienced by other minority populations at 
risk, both indigenous and recently immigrated. Culturally unique 
adaptive resources might be explored in ancillary family/community 



14 Latino Mental Health 



informant interviews such a study would require. The nesting of eth- 
nographic studies and biomedical measures within such future 
epidemiologic, multi-site studies would be of particular value. 

Although expensive, the cost would be small compared to the price 
of our ignorance concerning the mental health requirements of what 
will soon be the nation's largest ethnic minority group, which is 
already per capita the most abundant in children and youth. The data 
to be derived from such a major investigation would be essential to 
the design of Hispanic mental health services for the beginning of 
the next century. 



References 

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Burnam, M.A.; Hough, R.L.; Telles, C.A.; Karno, M. and Escobar, J.I. 
(1987). Measurement acculturation in a community population of 
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105-130. 

Burnam, M.A.; Stein, J. A.; Golding, J.M.; Siegel, J.M.; Sorenson, S.B.; 
Forsythe, A.B. and Telles, C.A. (1988). Sexual assault and mental dis- 
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Burnam, M.A.; Hough, R.L.; Karno, M.; Escobar, J.I. and Telles, C.A. 
(1987). Acculturation and lifetime prevalence of psychiatric disorders 
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Social Behavior, 28, 89-102. 

Burnam, M.A.; Hough, R.L.; Escobar, J.I.; Karno, M.; Timbers, D.M.; 
Telles, C.A. and Locke, B.Z. (1987). Six-month prevalence of specific 
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Cueliar, I.; Harris, L.C. and Jasso, R. (1980). An acculturation scale for 
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The Prevalence of Mental Disorders 1 5 



Fabrega, H.Jr.; Swartz, J.D. and Wallace, C.A. (1968). Ethnic differences 
in psychopathology-II. Specific differences with emphasis on the 
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Golding, J.M.; Stein, J. A.; Siegel, J.M.; Burnam, M.A. and Sorenson, 
S.B. (1988). Sexual assault history and use of health and mental health 
services. American Journal of Community Psychology 16 (5), 625-644. 

Golding, J.M.; Siegel, J.M.; Sorenson, S.B.; Burnam, M.A. and Stein, 
J. A. (1989). Social support sources following sexual assault, Journal of 
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Helzer, J.E.; Robins, L.N.; McEvoy, L.T.; Spitznagel, E.L.; Stolzman, 
R.K.; Farmer, A. and Brockington, I.F. (1985). A comparison of cli- 
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Hollingshead, A.B. and Redlich, R.C. (1958). Social class and mental ill- 
ness. New York: John Wiley. 

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mental health services by Los Angeles Mexican- Americans and non- 
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233-238. 

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Santana, F. and Bol, J.H. (1987). Lifetime prevalence of specific psy- 
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16 Latino Mental Health 



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J. A. (1989). Resistance to sexual assault: Who resists and what happens? 
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J. A. (1987). The prevalence of childhood sexual assault: The Los An- 
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Epidemiology, 126(6), 1141-1153. 

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M.A. (1987). The prevalence of adult sexual assault: The Los Angeles 
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(1987). Which Mexican- Americans underutilize health services? Ameri- 
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(1988). Factors affecting the probability of use of general and medical 
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Research on the Mental Health of 
Mexican Origin Children and Adolescents 

Robert E. Roberts, Ph.D. 



There are virtually no data on the mental health of Mexican ori- 
gin children and adolescents. On the one hand, given the limited data 
available on the epidemiology of mental disorders in the Mexican 
origin population generally (Cervantes and Castro, 1985; Cuellar and 
Roberts, 1984), it should come as no surprise that there are few data 
on children and adolescents. On the other hand, given that children 
and adolescents make up a much larger proportion of the Mexican 
origin group compared to other groups, that this segment of the 
population is growing rapidly, and that the social circumstances of 
Mexican origin children are disadvantaged relative to other groups, 
it is surprising there are so few data. 

As a consequence of the extreme paucity of data, the following 
discussion is developed in three parts. First, available research is 
reviewed in terms of what it can tell us regarding the psychological 
well-being of Mexican origin youth. Second, some initial results are 
presented from the first nationwide survey that has collected data 
on the mental health status of Black and Hispanic youth. Third, a 
case is made for further research on the mental health of Mexican 
origin youth and some alternate strategies for acquiring such data 
are outlined. 

The Evidence 

A recurring theme concerning this segment of American society 
is that of its uniqueness. There is consensus that the Mexican ori- 
gin population represents from many perspectives a group that is so- 
cially, culturally, historically, demographically, and geographically 
unique (Cervantes & Castro, 1985; de la Garza, Bean, Bonjean, 
Romo, & Alvarez, 1985; Levine & Padilla, 1980; Martinez & Men- 
doza, 1984; Ramirez, 1983; Vega & Miranda, 1985). Such a popu- 
lation is inherently intriguing to an epidemiologist since it implies 



18 Latino Mental Health 



that there may be unique aspects to such a population's illness ex- 
perience as well. 

A decade ago there were almost no epidemiologic data available 
on mental disorders among people of Mexican origin. This situation 
has changed dramatically, particularly in the past several years. 
Studies have been carried out in Los Angeles (Burnam, Hough, 
Escobar, Karno, Timbers, Telles, & Locke, 1987; Frerichs, Aneshen- 
sel & Clark, 1981; Karno, Hough, Burnam, Escobar, Timbers, San- 
tana, & Boyd, 1987), Alameda County (Roberts and Vernon, 1984), 
the central valley of California (Vega, Warheit, Buhl-Auth, & Mein- 
hardt, 1984), El Paso, Texas (Burnam, Timbers & Hough, 1984), 
and San Antonio, Texas (Markides, Martin and Sizemore, 1980). In 
addition, two national surveys have been conducted (Moscicki, Rae, 
Regier, & Locke, 1987; Ortiz & Arce, 1984). Two general conclu- 
sions emerge from this still admittedly small knowledge base. First, 
the prevalence of both demoralization and clinical psychiatric dis- 
orders among persons of Mexican origin is of the same general mag- 
nitude as has been reported for other populations. Second, although 
the crude prevalence rates for some disorders in the Mexican origin 
population are higher than for other groups, statistical adjustment 
for differences in demographic and socioeconomic composition 
among the different ethnic groups usually eliminates the initial 
differentials observed. Thus far, there seems to be little evidence that 
there is anything remarkable about the mental health of this popu- 
lation in terms of the prevalence of mental disorders. If anything, 
one is struck by the similarities rather than the disparities between 
Mexican origin and other populations in terms of prevalence data. 
Thus far, there are no incidence data available on the Mexican ori- 
gin population (and few for other U.S. populations). 

The studies just reviewed were all on adults. What about studies 
of children and adolescents? Epidemiologic data on mental disorders 
among Mexican origin children and adolescents are virtually non- 
existent. A systematic search yielded not a single published report 
of community-based incidence or prevalence data on mental dis- 
orders in this population. Indeed there have been few studies that 
have focused on the psychological well-being of Mexican origin 
youth, period. 

For example, Diaz-Guerrero (1976) compared Mexican origin chil- 
dren and non-Hispanic children on the Test- Anxiety Scale (TASC) 
and from the AX variable of the Holtzman Inkblot Test (HIT) and 
reported that while Mexican origin children exhibited more test 



Research on Mental Health 19 



anxiety, non-Hispanic children exhibited more underlying symbolic 
anxiety. Tuddenham, Brooks, and Milkovich (1974) compared 9-, 
10-, and 11-year old children of Anglo, Black, Oriental, and Mexi- 
can origin whose mothers rated their behavior on a 100-item be- 
havior inventory. The results were difficult to summarize, but in 
general, Mexican origin mothers described their children as more 
tense and their sons as overly generous. 

O'Donnell, Stein, Machabanski, and Cress (1982) compared Mex- 
ican origin and Anglo children aged 3-5 years on a modified Behavior 
Problem Checklist (BPCL), and found that Anglo children had more 
anxiety-withdrawal symptoms than their Mexican origin counter- 
parts. In an earlier study, Touliatos and Lindholm (1976) compared 
Anglo and Mexican origin children in grades K-5 on the BPCL. 
Teachers rated the Anglo children as having more problems in three 
areas: conduct disorder, inadequacy-immaturity, socialized delin- 
quency; however, not for personality disorders. Argulewicz and 
Miller (1984) administered the Revised Children's Manifest Anxi- 
ety Scale and the Child Anxiety Scale to 719 Anglo, Black and Mex- 
ican origin students in grades 1-3. Although their focus was 
methodological, the authors did report mean scores for the three 
groups. Blacks scored lower than the other two groups, but overall 
there was little difference in scores between the Anglo and Mexican 
origin groups. Helsel and Matson (1984) examined the Child Depres- 
sion Inventory in a sample of Anglo, Black and Hispanic youth 4- 
18 years of age. Older subjects manifested more symptomatology, 
but there was no effect for either gender or ethnic status. 

These studies obviously are extremely limited in scope and pro- 
vide no information concerning the burden (in terms of incidence 
and prevalence) of mental disorder among Mexican origin youth in 
either absolute terms or relative to other groups such as Anglos or 
Blacks. 

In fact, to my knowledge, the results of only two studies have been 
published to date in the United States which have as their focus men- 
tal disorders among Hispanic youth. Bird, Canino, Rubio-Stipec, 
Gould, Ribera, et al. (1988) assessed psychopathology using the 
Child Behavior Checklist (CBCL), and the Diagnostic Interview 
Schedule for Children (DISC), in a sample of 777 children and 
adolescents aged 4-16 years of age living in Puerto Rico. Based on 
their results, they estimated that the six-month prevalence of DSM- 
III disorders was 17.9 or 16 percent, depending on severity. The six- 
month prevalence of some of the more common disorders ranged 



20 Latino Mental Health 



from 4.9 percent for oppositional disorders to 2.8 percent for depres- 
sion/dysthymia to 1.3 percent for simple phobias. The six-month 
prevalence of depression is comparable to rates reported for adults 
(Roberts, 1988). 

Weinberg and Emslie (1987) completed a school-based survey of 
3,294 high school students in the Dallas metropolitan area, using the 
Beck Depression Inventory (BDI) and the Weinberg Screening Af- 
fective Scale (WSAS). The sample contained 1,825 Black (55.4 per- 
cent), 783 Anglo (23.8 percent), and 598 (18.2 percent) Hispanic 
adolescents. On the BDI, 22.6 percent scored as mildly depressed 
(scores of 10-15) and 18.1 percent as moderately to severely 
depressed. Hispanic females scored the highest proportion with 
moderate to severe depression (31.2 percent); Anglo males the lowest 
(8.6 percent). Using the Weinberg criteria, 13.4 percent were 
depressed with Hispanic females most depressed (22.4 percent) and 
Anglo males least depressed (7.9 percent). It is assumed the over- 
whelming majority of the Hispanics were of Mexican origin. 

A third study, not yet published, provides some additional infor- 
mation (albeit indirectly) about the mental health of Mexican ori- 
gin adolescents. Swanson and colleagues (Swanson, Linsky, 
Quintero-Salinas, Pumariega, & Holzer, 1989) conducted a school- 
based survey in grades 7-12 in three cities in the Rio Grande Valley 
of Texas, using the CES-D scale. Ethnic identifiers were omitted 
from the questionnaire, but school records indicate over 95 percent 
of the students were Mexican origin. Using the standard "caseness" 
criterion of a score equal to or greater than 16, 48.1 percent of the 
sample of 1,775 were depressed, 40.9 percent of the males and 53.7 
percent of the females. Using the more stringent criteria of scores 
of 21 + and 31 + , 33.9 and 15.0 percent, respectively of the sample 
were depressed. 

A fourth study, also not yet published, provides national data on 
depressive symptomatology among Anglo, Black, and Hispanic 
youth, including those of Mexican origin. What I would like to do 
now is present some data from this study. These data are some of 
the first reported from this particular survey. 



The 1985 NIDA Survey 

The data to be presented are taken from the 1985 National House- 
hold Survey on Drug Use, the eighth in a series of national surveys 
to measure the prevalence of drug use in the American household 
population aged 12 and over, conducted by the National Institute 
on Drug Abuse (NIDA). Essentially the same methodology has been 



Research on Mental Health 21 



used in each of the surveys. Respondents are interviewed in person 
in their homes by trained interviewers using self-administered answer 
sheets and other methodology intended to maximize the validity of 
responses to sensitive questions. The data are kept confidential 
and anonymous. The respondents are drawn randomly within age 
categories from a national multistage, area probability sample of 
households in the coterminous United States. The household popu- 
lation includes more than 98 percent of the U.S. population. 

For the 1985 NIDA Survey, the data were collected from June 
through December 1985 resulting in a total of 8,038 interviews and 
an overall response rate of 83 percent. In 1985, as in previous sur- 
veys, the younger age groups were oversampled in order to obtain 
more stable estimates of drug use for them. For the first time, in 
1985, Black and Hispanics also were oversampled. Based on respon- 
dent self-classification, race/ethnicity groups were classified as: (1) 
Hispanic in origin, regardless of race; (2) White, not of Hispanic ori- 
gin; and (3) Black, not of Hispanic origin. 

Composition of the 1985 NIDA Survey sample, in terms of age 
and ethnic status is summarized in Table 1 . As can be seen, roughly 
one-fourth of the overall sample falls into each of four age groups: 
12-17, 18-25, 26-35, and 35 and older. Of the 8,038 respondents, 
3,949 were Anglo (49.1 percent), 1,996 were Hispanic (24.8 percent), 
and 1,945 were Black (24.2 percent). Data on subjects 12-17 years 
of age are found in Table 2. The questionnaire and answer sheets 
were translated into Spanish, and respondents were given the option 
of being interviewed in English or Spanish. 

Table 1. Distribution of 1985 NIDA Sample by Age and Ethnic Status 







Ethnic Status 






Age Group 




Whites 


Hispanics 


Blacks 


Total 


12-17 


No 
°7o 


1,007 

25.5 


642 
32.2 


601 
30.9 


2,250 

28.5 


18-25 


No 


791 
20.0 


525 
26.3 


459 
23.6 


1,775 
22.5 


26-34 


No 


1,075 
27.2 


527 
26.4 


494 

25.4 


2,096 
26.6 


35 + 


No 


1,076 

27.3 


302 
15.1 


391 
20.1 


1,769 

22.4 


Total 




3,949 
100.0 


1,996 
100.0 


1,945 
100.0 


7,890 
100.0 



22 Latino Mental Health 



Table 2. Ethnic X Gender Composition of the 12-17 Age Group, 
1985 NIDA Survey 







Gender 








Ethnic Group 


Male 

N % 


Female 

N % 


Total 

N % 


Anglo 


523 


47.2 


470 


42.9 


993 


45.1 


Black 


271 


24.4 


319 


29.1 


590 


26.8 


Mexican Origin 


197 


17.8 


197 


18.0 


394 


17.9 


Other Hispanic 


117 


10.6 


109 


10.0 


226 


10.2 


Total 


1,108 


100.0 


1,095 


100.0 


2,203 


100.0 



Measures 

The 1985 NIDA Survey was the first in the series to include a 
measure of depression, or any measure of psychopathology other 
than substance abuse. This construct is operationalized using 12 
items taken from the Center for Epidemiologic Studies Depression 
(CES-D) Scale. The CES-D has been used in a number of commu- 
nity surveys, including Kansas City, Missouri, and Washington 
County, Maryland (Comstock & Helsing, 1976; Radloff, 1977), 
Alameda County, California (Roberts, 1980), Los Angeles County, 
California (Frerichs, Aneshensel & Clark, 1981), and in the National 
Health Survey (Sayetta & Johnson, 1980), among others. 

Specifically, the scale was designed to measure the current level 
of depressive symptomatology, with emphasis on the affective com- 
ponent, depressed mood (Radloff, 1977). Items were selected for in- 
clusion from previously validated depression scales to represent the 
major components of depressive symptomatology identified from 
the clinical literature and factor analytic studies (Radloff, 1977). 
These components are depressed mood, feelings of guilt and worth- 
lessness, feelings of helplessness and hopelessness, psychomotor 
retardation, loss of appetite, and sleep disturbance. 

The reliability and validity of the scale have been assessed on clinic 
populations (Craig & Van Natta, 1973; Roberts, Vernon & 
Rhonades, 1989; Weissman, Sholmaskas, Pottenger, Prusoff, & 
Locke, 1977;) and on respondents from a number of community 
studies (Comstock & Helsing, 1976; Radloff, 1977; Roberts, 1980). 
Analyses indicate that the scale is reliable and shows fairly good con- 
vergent and discriminant validity in the subgroups examined. 



Research on Mental Health 23 



The CES-D Scale may be either self- or interviewer-administered 
and consists of 20 items. The time frame for reporting symptoms is 
the past week. Scores may range from to 60 with high scores in- 
dicating more negative symptomatology. Items are weighted by the 
frequency of occurrence so that a high score may indicate either 
many symptoms of a short duration or fewer symptoms experienced 
for longer periods of time. The usual response formats are: (0) Rarely 
or none of the time (less than a day); (1) some or little of the time 
(1-2 days); (2) occasionally or a moderate amount of the time (3-4 
days); and (3) most or all of the time (5-7 days). 

The original 20 CES-D items are presented in Table 3, with the 
12 included in the 1985 Survey identified. For the 12-item version, 
scores range from 0-36. Ethnic status is derived from two questions, 
one inquiring about ethnic origin generally (e.g., Black or White, not 
of Hispanic origin; or Hispanic) and one about Hispanic origin (e.g., 
Puerto Rican, Mexican, Cuban, other). 

In presenting these initial data, two types of results are presented: 
internal consistency reliabilities and prevalence of depressive symp- 
toms by age, gender, and ethnic group. Of the various measures 
of internal consistency reliability (split-half; Kuder-Richardson; 
Cronbach's alpha), the one most frequently used in recent years in 
assessing scales of well-being is Cronbach's coefficient alpha since 
it can be used with multiple-scored items, e.g., response categories 
such as "often," "occasionally," "never" (Cronbach, 1951; No- 
vick & Lewis, 1967). 

There are few estimates of the reliability of measures when used 
with Mexican American samples although the data from several 
Hispanic community samples suggest that reliability may well be as 
high as for Anglos and Blacks (Dohrenwend, Shrout, Egri, & Men- 
delsohn, 1980; Roberts, 1980; Vega, Kolody & Warheit, 1985). 
However, no reliability data exist for community samples using the 
12-term version of the CES-D. Furthermore, we do not know 
whether reliability will vary across subgroups defined in terms of eth- 
nic status (Anglo, Black, Mexican- American), language (Spanish, 
English), or age (adolescent/younger adults/older adults), gender 
or education. Thus, the first order of business will involve reliabil- 
ity assessments. 

Several strategies can be employed to estimate prevalence. The 
most straightforward approach involves selecting a criterion score 
for estimating "caseness." This can be done a number of ways, such 
as defining as "cases" respondents whose depression scores are 



24 



Latino Mental Health 



Table 3. The Center for Epidemiologic Studies Depression Scale Items 

Full Scale NIDA Version 

1. Bothered by things that usually don't bother me * 

2. Did not feel like eating; appetite was poor * 

3. Felt could not shake off the blues even with help 

from family or friends * 

4. Felt just as good as other people X 

5. Had trouble keeping mind on what was doing .... X 

6. Felt depressed X 

7. Felt that everything was an effort X 

8. Felt hopeful about the future X 

9. Thought life had been a failure * 

10. Felt fearful * 

1 1 . Sleep was restless X 

12. Was happy X 

13. Talked less than usual * 

14. Felt lonely * 

15. People were unfriendly X 

16. Enjoyed life X 

17. Had crying spells X 

18. Felt sad * 

19. Felt that people dislike me X 

20. Could not "get going" X 

*Omitted 



above the mean or whose score places them in the upper quartile, 
etc. One strategy we have used with good results is one standard devi- 
ation or more above the mean for the total sample. For such ana- 
lyses, the CES-D items are scored in the usual fashion. That is, the 
12 items are summed, with a higher score indicating greater impair- 
ment. Prevalence is then calculated as the percent of a group with 
scores above the particular cut point. 

There are other possibilities, of course. Following the lead of 
Wells, Klerman and Deykin (1987), prevalence can be calculated as 
the percent reporting symptoms which lasted 3 days or more, or 
symptoms which lasted 5 days or more. Such a procedure places 
more emphasis upon duration of symptoms, ostensibly indicating 
more chronic and/or severe impairment. 



Research on Mental Health 25 



For this presentation, three measures of impairment are presented: 
mean scores, the percent scoring above the grand mean, and the per- 
cent scoring one standard deviation or more above the grand mean. 
Using these measures precludes comparisons with the results of other 
surveys of adolescents which have used the CES-D. All other sur- 
veys have used the full 20 items and, as yet, we do not have a relia- 
ble algorithm for comparing CES-D 12 and CES-D20 scores directly. 

Findings 

Cronbach's alpha (shown in Table 4) for the total sample was 
0.75, which compares favorably with that reported for the full 20- 
item version of the CES-D (generally above 0.8), given the attenu- 
ated item set. There was in general little variation across subgroups, 
most being in the 0.7-0.8 range. There was slightly lower (.68) reli- 
ability for the adolescent group. Based on these findings, the CES- 
D12 seems to be operating in an acceptable fashion in the subgroups 
of interest. 

The distribution of scores seems coherent as well (shown in Table 
5). In terms of age, there is nothing dramatic. Those 35 years of age 
or older consistently have the lowest depression values. The age 
threshold seems to be 25, and those under that age report more 
depressive symptomatology across all three measures. However, the 

Table 4. Internal Consistency Reliability (a) for Gender, Age, 
Ethnic Status, and Total Sample, 1985 NIDA Survey 



Group 




Alpha (a) 


N 


Gender 


Male 


0.71 


3462 




Female 


0.76 


4431 


Age 


12-17 


0.68 


2219 




18-25 


0.75 


1775 




26-34 


0.79 


2125 




35 + 


0.77 


1774 


Ethnic Status 


Black 


0.72 


1912 




Anglo 


0.75 


3889 




Hispanic 


0.76 


1194 




Mexican 


0.74 


1194 


Total 




0.75 


7893 



26 



Latino Mental Health 



Table 5. Distribution of CES-D12 Scores by Gender, Age, and 
Ethnic Status: Mean Scores and Prevalance Rates (%) 



Group 


X Score 


%>X* 


%>1S.D.(X)\ 


P Value 


Age 










12-17 


6.73 


46.2 (1036) 


16.3 (365) 


.000 


18-24 


6.60 


43.5 ( 787) 


17.4(315) 




26-34 


5.68 


33.9 ( 733) 


14.0 (302) 




35 + 


5.43 


33.1 ( 598) 


13.6(245) 




Ethnic Status 










Anglo 


5.48 


33.3(1312) 


12.2 (480) 




Black 


6.95 


47.0 ( 913) 


18.6 (362) 


.000 


Mexican 
Origin 


6.72 


44.9 ( 548) 


18.0(220) 


.413 


Other 
Hispanic 


6.46 


43.0 ( 321) 


18.2(136) 




Gender 










Male 


5.53 


35.4(1244) 


12.0 (423) 


.000 


Female 


6.60 


42.4(1910) 


17.9 (804) 





^Percent scoring above total sample mean. 

tPercent scoring one standard deviation or greater above the total sample mean. 



age effect is not dramatic overall, which is what has been reported 
in general. In terms of ethnic status, the principle effect seems to be 
a minority status effect. That is, Anglos consistently report less 
depression than Blacks or Hispanics, including respondents of Mexi- 
can origin, in fact dramatically less. Based on comparisons of crude 
rates, that is what has been reported in other studies (Roberts, 1987b; 
1988). As has been reported in most studies using the CES-D20, there 
also was a dramatic gender effect, with females reporting much more 
depression. 

Turning to the age group 12-17 (defined here as children and 
adolescents), we find the same general effect for gender (shown in 
Table 6). Within each ethnic group examined, and on each of the 
outcome measures, females report more depression than males. 
Perusal of the ethnic effect reveals a slightly different pattern for the 
youngest segment of the sample. Among males, the lowest rates are 
reported by other Hispanics (largely Puerto Rican and Cubans), with 
Anglos and Blacks intermediate (and little different), and Mexican 



Research on Mental Health 27 



origin youth reporting the most depression. However, the real con- 
trast for males is between the Anglo and Mexican origin groups on 
the standard deviation prevalence measure (p = 0.02). The Mexi- 
can origin/Other Hispanic contrast also was significant on this meas- 
ure (p = 0.05). Among females, there is a slightly different pattern, 
with other Hispanics reporting least, Anglos intermediate, and Black 
and Mexican origin youth reporting the most depressive symptoms. 
For females, the contrasts of most interest are Anglo versus Mexi- 
can origin on the percent scoring above the mean (p < 0.05) and An- 
glo versus Black (p < 0.001). On the standard deviation prevalence 
measure, the two contrasts to note are Anglo versus Mexican ori- 
gin (p < 0.05) and Mexican origin versus other Hispanic (p < 0.05). 
It should be noted that while these results mirror in many respects 
what has been reported for adults, thus far they are based on com- 
parisons of crude rates. As I have noted elsewhere (Roberts & Ver- 
non, 1984), adjustment for demographic and socioeconomic 
differences among ethnic groups typically eliminates observed 
differentials in crude rates. As can be seen in Table 7, adjustment 
for age, gender, and perceived health status of the adolescent, as well 
as the occupational status of the head of the household, reduces the 
crude differentials but only marginally. After adjustment, there is 
still a significant difference among the four ethnic groups in terms 
of mean scores and the percent scoring one or more standard devi- 
ations above the grand mean. On both measures, the difference is 
attributable to higher rates for the Mexican origin adolescents. On 



Table 6. Distribution of CES-D12 Scores by Gender and Ethnic Status: 
Among 12-17 Year-Olds: Mean Scores and Prevalance Rates (%) 







Male 




Female 


Ethnic 














Group 


X 


%>X* 


%>1S.D.(X) 


X 


%>X* 


%>ls.D.(X)-\ 


Anglo 


6.10 


41.7(218) 


11.7(61) 


6.90 


43.9(206) 


18.1 (85) 


Black 


6.11 


41.7(113) 


12.2 (33) 


7.80 


57.4(183) 


21.0(67) 


Mexican 
Origin 


6.93 


48.7 ( 96) 


18.3 (36) 


7.94 


53.3 (104) 


25.6 (60) 


Other 

Hispanic 


5.63 


41.0 ( 48) 


10.3(12) 


6.34 


45.9 ( 50) 


14.7(16) 


P-Value 




.33 


.08 




.001 


.07 



*Percent scoring above total sample mean. 

tPercent scoring one standard deviation or greater above the total sample mean. 



28 



Latino Mental Health 



Table 7. Crude and Adjusted* CES-D Measures by Ethnic Group for 
12-17 Year-Olds 







Ethnic 


Group 
Mexican 


Other 




CES-D 12 


Anglo 


Black 


Origin 


Hispanic 


Beta 


Measures 


(n = 986) 


(n = 586) 


(n = 390) 


(n = 221) 


Coefficient 


Mean (X) 












Crude 


6.47 


7.05 


7.46 


6.06 


09** 


Adjusted 


6.56 


6.56 


7.46 


6.14 


.08** 


%>X 












Crude 


42.0 


50.0 


51.0 


44.0 


.08** 


Adjusted 


43.0 


46.0 


51.0 


44.0 


.06 


%>1S.D.(X) 












Crude 


14.0 


17.0 


22.0 


12.0 


.08** 


Adjusted 


15.0 


15.0 


22.0 


14.0 


.07* 



t Adjusted for age, gender, and perceived health status of adolescent, and occupa- 
tion of head of household. 
*P <.05 
**P <.001 



the other measure, the Mexican origin group also has a higher rate, 
but not significantly so. 

Risk Factors 

What is the evidence concerning risk factors for psychological dis- 
orders among people of Mexican origin? Does there appear to be 
anything unique about the Mexican origin experience that increases 
or decreases the risk of developing psychological disorders? For most 
purposes, risk factors can be grouped into two broad classes: psy- 
chosocial or biological. As yet, we have no data on the role of bio- 
logical risk factors in the etiology of disorders such as depression, 
schizophrenia or alcoholism in minority populations. The same can 
be said of family history, a factor which combines in many respects 
biological (i.e., genetic) and psychosocial (i.e., family environment) 
components of risk in one surrogate measure. This should not be sur- 
prising, since research findings on the role of biological factors and 
family history in the majority population are neither comprehensive 
nor compelling for most psychological disorders. There are data sug- 
gesting both genetic and biochemical origins for diseases such as 
schizophrenia, depression, and alcoholism, but thus far the role of 



Research on Mental Health 29 



such factors in the etiology of these disorders is neither well-described 
nor well-understood (Regier & Allen, 1981). 

What about the role of social, psychological and cultural variables 
in the etiology of mental disorders in the Mexican origin population? 
Where psychosocial risk factors are concerned, the evidence accumu- 
lated thus far also is not very instructive. A number of authors have 
reviewed what is known about psychosocial factors both in the 
general population (Akiskal, 1979; Eaton, 1981; Roberts, 1987b), 
and the Mexican origin population (Cuellar & Roberts, 1984; Cer- 
vantes & Castro, 1985; Vega, Warheit & Meinhardt, 1985; Roberts, 
1987a). In general, psychosocial risk factors can be grouped into one 
of three general classes (Roberts, 1987b): status attributes (age, 
gender, social class, marital status, and ethnic background), personal 
resources (personality, coping skills, or social support), and life 
stress, including life events such as illness, death of a significant 
other, and immigration, as well as, chronic strains such as, marital 
difficulties and acculturative stress. With regard to the role of life 
stress and personal resources in the occurrence of depressive illness 
or symptoms among Mexican origin people, we know practically 
nothing. With regard to whether and how social statuses in this 
population affect risk of depression, we are not much better off 

Through 1984, data had been published from only nine 
community-based, epidemiologic studies of mental health in this 
population conducted over a period of two decades. All of the 
studies employed measures of demoralization as their outcome vari- 
able. What these studies tell us about the role of such factors as age, 
gender, social class, marital status, and ethnicity has been sum- 
marized succinctly by Vega, Warheit and Meinhardt (1985). In the 
case of gender, social class, and marital status, rates appear to be 
higher for women, those in the lower socioeconomic strata, and 
those who are separated and divorced, which is what has been 
reported for other U.S. adults. Vega, Hough and Miranda (1985) 
note that age seems to operate differently in several studies than has 
been reported for non-Hispanics, suggesting rates are higher for 
older Mexican Americans, perhaps related to marginal acculturation, 
foreign birth, and minimal educational achievement. Again, 
although the existing data are extremely limited, there seems little 
evidence to suggest that for generic risk factors such as gender, mar- 
ital status, or social class, the risk profile is different for adults of 
Mexican origin. These results on risk factors are all based on studies 



30 Latino Mental Health 



of adults; there is no comparable compilation of risk factor profiles 
for Mexican origin children and adolescents. 

There is one dimension of the life experience of people of Mexi- 
can origin that, at least from a theoretical perspective, might con- 
stitute a unique risk. This is acculturation, the sociocultural 
adjustment occurring when two or more differing "cultures" inter- 
act. Clearly the concept of acculturation has come to occupy a cen- 
tral place in social science discussions of the Mexican origin 
experience, particularly in regard to its implications for psychological 
functioning. 

A number of papers examined and reviewed this issue (Burnam 
et al., 1987; and Roberts, 1987a, b;). Based on results thus far, 
research has not been able to clearly delineate the role of accultu- 
ration in the process of successful psychological adaptation among 
either adults or children. Mexican origin, its attendant culture, and 
its interaction with mainstream American culture may have mental 
health implications for those involved in the acculturation process, 
but thus far we have been unable to convincingly demonstrate the 
nature or the magnitude of the effect. 

Research on risk factors for psychiatric disorders among Mexi- 
can origin youth is essentially nonexistent. Research on risk factors 
for depressive symptoms using the NIDA data is still in progress. 
There are, however, some preliminary results. In Table 8 are pre- 



Table 8. Factors Associated with Emotional Disorders Among 
Children and Adolescents 



Study 


Age 


Gender 


SES 


Ethnic Status 


Anderson et al., 1989 


NA 


B<G 


NA 


NA 


Birdetal., 1988 


NA 


NA 


L<H 


NA 


Velezet al., 1989 


Y<0 


B<G 


L>H 


NA 


Costello, 1989 


Y = 


B<G 


NA 


NA 


Offordetal., 1989 


Y<0 


B<G 


L>H 


NA 


Weinberg & Emslie, 1987 


NA 


B<G 


NA 


A<B<H 


Roberts 


Y = 


B<G 


L>H 


A<B<MO 



Y = younger, O = older 

B = boys, G = girls 

L = lower socioeconomic status, H = higher socioeconomic status 

A = Anglos, B = Blacks, MO = Mexican Origin, H = Hispanic 



Research on Mental Health 3 1 



sented some initial findings for four factors: age, gender, socio- 
economic status, and ethnic status. Comparative data from recent 
community-based studies of children and adolescents are taken 
primarily from a recent review by Costello (1989). The NIDA results, 
of course, are for the CES-D12. Those from Costello are for "emo- 
tional disorders,'' including depressive and anxiety disorders. For 
the NIDA survey, among 12-17 year-olds, there was little age effect; 
girls reported more depressive symptoms than boys, lower status 
reported more than higher status youth, and minority youth reported 
more than majority group youth in a majority of the comparisons. 
Mexican origin youth reported much higher rates of depression. Our 
data thus are consistent with those reported by Weinberg and Emslie 
(1987). The patterns for gender and socioeconomic status are con- 
cordant with those from other studies reviewed by Costello, whereas 
the age effect is mixed. 

Research Issues 

I believe that I have demonstrated that we know very little about 
the epidemiology of psychological disorders among Mexican origin 
children and adolescents. The lack of research on the mental health 
of the youth of this American sub-nation is indefensible scientifically 
or politically, given its size, social characteristics and rapid growth. 
Clearly there is an urgent need, as we approach the twenty-first cen- 
tury, for more systematic knowledge about the mental health of this 
group. Thus, we need more research, but I believe the research 
should be guided and informed by issues that have limited the use- 
fulness of much of the research on adults. 

What are the research questions which should drive future 
epidemiologic investigations of child and adolescents disorders in the 
Mexican origin population? I offer the following list as a point of 
departure: 

1 . What is the prevalence of clinical disorders? 

2. What is the incidence of clinical disorders? 

3. What is their natural history? 

4. What are the consequences of clinical disorders? 

5. What are the etiologic factors involved? 

6. What is the role of generic risk factors such as age, gender, so- 
cioeconomic status, social support, life events and chronic strains, 
or family history vis-a-vis psychiatric disorders among Mexican 
origin youth? 



32 Latino Mental Health 



7. What are the joint effects of minority status, ethnic culture and 
social class on psychiatric risk among Mexican origin youth? 

8. What is the impact of acculturation? 

Clearly there are many more, hypothesis-specific research issues 
that could be addressed (Institute of Medicine, 1989). I submit, 
however, that these represent the most basic questions, ones that 
are fundamental to an understanding of the epidemiology of men- 
tal, behavioral, and developmental disorders among children and 
adolescents. 

Psychological and behavioral disorders clearly are the result of 
lifelong interactions among biological, psychological, and socio- 
environmental factors (Cooper & Morgan, 1973; Regier & Allen, 
1981; Roberts, 1987b). Accordingly, fuller understanding of the 
etiology of psychological disorders will require explanatory models 
which reflect the presumed multifactorial nature of the phenome- 
non being studied. Thus far, no studies of Mexican origin adults or 
children satisfy this condition. Research results published to date do 
not even permit us to answer the question of whether Mexican ori- 
gin increases, decreases, or has no effect on risk of psychological dis- 
order, in general, or in terms of specific problems, such as bipolar 
and unipolar depression, anxiety disorders, or alcoholism. 

Three types of methodologic inadequacies have compromised 
much of our research efforts. First, sampling has been a continu- 
ing problem, both in terms of size and representativeness. Almost 
without exception, studies have been based on data from small sam- 
ples typically drawn from a single community, barrio, or school. 
Such samples clearly do not represent the diversity of the Mexican 
origin population in the United States, nor do they permit explora- 
tion of the mental health experience in Mexican origin subgroups de- 
fined by geographic region, rural/urban residence, language use, 
birthplace, generation, or social class, all considered important fac- 
tors shaping the life experience of this ethnic group (Cervantes & 
Castro, 1985; Vega, Hough & Miranda, 1985). 

A second, principal deficiency in epidemiologic studies of men- 
tal disorders among persons of Mexican origin has been the reliance 
on cross-sectional prevalence studies rather than prospective inci- 
dence studies. Identification of factors associated with prevalence 
do not necessarily tell us anything about etiology. Factors related to 
prevalence actually may be the result of duration effects and not etio- 
logic effects. That is, the factors sustain the illness rather than cause 
it. Thus far, there have been no data published from a prospective, 



Research on Mental Health 33 



epidemiologic study of risk factors for mental disorder in this group. 
Where studies of children and adolescents are concerned, a longitu- 
dinal perspective is essential if interactions of biological and social 
developmental factors with culture and social class are to be ac- 
curately assessed. 

Measurement has been problematic, and several issues are worth 
noting. First, with the exception of three studies (Burnam et al., 
1987; Moscicki et al., 1987; Vernon & Roberts, 1982), all of our pub- 
lished information from community-based epidemiological studies 
of the mental health of this population was obtained using nonclin- 
ical, nonspecific measures of distress. Such measures tell us noth- 
ing about the prevalence, type, or severity of clinically diagnosable 
psychiatric disorder in these subgroups. From the perspective of 
epidemiology, as well as program planning and evaluation, we need 
both types of data (Roberts, 1987b). Second, we know very little 
about the reliability and validity of most of our measures of psycho- 
logical dysfunction when used with minority youth. This is partic- 
ularly true in the case of some of the structured diagnostic interviews 
that have been developed for use with children and adolescents, such 
as the Diagnostic Interview for Children and the Schedule for Af- 
fective Disorders for School Age Children (Edelbrock & Costello, 
1988). A major problem in this regard has been the lack of assess- 
ment procedures that are adequately translated and standardized 
with English and Spanish equivalency demonstrated (Cuellar & 
Roberts, 1984). Third, even when the reliabilities appear to indicate 
equivalence across ethnic or cultural groups, there is the issue of 
which symptoms are elicited in a reliable fashion. That is, often we 
do not know whether the phenomenology of disorder is similar 
across groups. Other than a few studies of folk medicine syndromes, 
we have little evidence about whether and how Mexican cultural 
background shapes psychopathology in ways unique to this popu- 
lation (Cuellar & Roberts, 1984) in children or adults. 

I would like to end this discussion by outlining some suggested 
research strategies for epidemiologic investigations of the causes and 
consequences of psychological disorders among Mexican origin chil- 
dren and adolescents: 

1. First, we need to develop conceptual frameworks that explicitly 
acknowledge that the causes and consequences of psychological and 
behavioral disorders involve the interactions of biological, psycho- 
logical, and socioenvironmental factors. Furthermore, we need 



34 Latino Mental Health 



multivariate strategies to compare the contributions of diverse ar- 
rays of risk factors, thereby facilitating the simultaneous testing of 
competing hypotheses. 

2. We also need to employ more longitudinal designs, focusing 
on both antecedents and consequences of disorders. 

a. Followup periods should be designed to encompass the passage 
of critical developmental stages. 

b. The focus should be on prevalence and incidence, as well as 
natural history (duration, remission, recurrence). 

3. Our sampling designs should address the low base rate problem 
versus the need for sufficient numbers of cases of specific disorders. 

a. This means, among other considerations, more innovative use 
of multi-stage strategies for case-ascertainment, and 

b. Sampling strategies recognizing the geographic and socioeco- 
nomic characteristics of minority populations. 

4. We should make greater use of multi-method strategies for as- 
sessing the presence and severity of psychopathology among children 
and adolescents from minority populations. 

a. We should consider the use of both self-report symptom scales 
and diagnostic interviews. 

b. Additionally, we should use observational techniques and 
reports of significant others (parents, teachers, siblings). 

5. Comparative designs are imperative, involving at the very least 
a two-group comparison — the majority and the minority group of 
interest, thereby permitting us to: 

a. Focus on comparative descriptive profiles (incidence, preva- 
lence, severity, natural history, etc.) and 

b. Focus on comparative etiologic profiles (relative risks for the 
same factors and identification of different factors, etc.). 

Research which incorporates these strategies will go a long way 
toward generating more useful information on the occurrence of 
mental disorders among Mexican origin children and adolescents, 
as well as the antecedents and consequences of these disorders. 
Whatever form such research assumes, however, it is imperative that 
it be done. 



Research on Mental Health 35 



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3 



The Role of Cultural Factors in 

Mental Health Problems of 

Hispanic Adolescents 

William A. Vega, Rick S. Zimmerman 

George J. Warheit, David Jackson, 

George J. Warheit, David Jackson 

Andres Gil, Jan Sokol-Katz 



The two major objectives of this paper are to describe a large 
epidemiologic field survey, which is designed to determine the rela- 
tionships between cultural adaptation and psychosocial well-being 
among a sample of Hispanic adolescents; and to identify some of 
the most salient theoretical and methodological problems associated 
with attempts to conduct large scale, empirical studies focusing on 
this issue. 

Establishing the relationships between cross-cultural adaptation 
and its mental health sequelae represents a difficult research arena 
for those interested in developing descriptive and/or explanatory 
models based on empirically derived data. This is undoubtedly one 
of the reasons why so little empirical research on the topic has been 
reported (Vega et al., 1985; Rogler et al., 1989). Nevertheless, the 
issues involved are extremely important ones for psychiatric epidemi- 
ologists, particularly in light of the increased numbers of new im- 
migrants coming to the United States. Although all immigrants are 
undoubtedly compelled to adapt to life in a new culture, our research 
is primarily interested in adolescents, a group we believe to be at un- 
usual risk for intercultural conflicts associated with adaptation, ac- 
culturation, and assimilation. Specifically, we are addressing issues 
related to these topics, which we believe have the potential to pro- 
vide us with the foundations on which an explanatory model can be 
constructed: (1) the cultural orientation of the adolescent; (2) the ac- 
culturative conflicts between adolescents and parents; (3) the adjust- 
ment and acculturative strains experienced by both the family and 
the adolescent in American society; and (4) the protective role of 
specific cultural values as they related to both coping and conflict. 



42 Latino Mental Health 



For decades, ethnographic researchers have noted that immigrants 
and their children are subjected to psychological stresses as a result 
of the social, psychological and cultural processes inherent in moving 
from one social and cultural environment to another one. For ex- 
ample, Mead (1949) distinguished first generation from second 
generation cultural accommodations, referring to the former as a 
"primary-contact condition" and to the latter as a "secondary- 
contact condition". In making this comparison, Mead noted that 
a secondary-contact condition is probably more personally disor- 
ganizing because of the lack of consistent socialization and possible 
conflicts between parental cultural expectations and those of the 
wider society. More recently Szapocznik et al. (1977) and Szapocznik 
and Truss (1978) noted in their clinical studies that there is a pattern 
where large differences in cultural orientation between Cuban par- 
ents and their male adolescent children are related to behavior 
problems and drug use among the offspring (Szapocznik, et al., 
1977; Szapocznik & Truss, 1988). In addition, others have reported 
systematic observations which indicate that the children of im- 
migrants who are exposed to competing cultural definitions, values, 
and behaviors may be more vulnerable to mental health or conduct 
problems than those not experiencing these conflicts (Favazza, 1980; 
Vega et al., 1983; Ramirez, 1984). 

These earlier research efforts have helped identify many of the risk 
factors and the mediating variables related to social and cultural 
adaptation and their psychosocial impacts. However, if we are to in- 
crease our understanding of these dynamic and complex processes, 
prospective studies are needed. Moreover, these studies must be 
based on comprehensive designs which integrate existing theories and 
empirical approaches (Kessler & Greenberg, 1981). These designs 
will, of necessity, combine elements of traditional, descriptive 
epidemiology, acculturation research, social psychological stress the- 
ory, theories of adolescent development, and the measurement of 
mental health status. Research designs lacking this comprehensive 
and methodological integration will not be able to address the fun- 
damental questions concerning the relationships between accultura- 
tion processes, including personal, social, and cultural conflicts, and 
the mental health status of the adolescent children of immigrants. 
Some questions we are addressing in our present research include the 
following: (1) do conflicts between parents and adolescents occa- 
sioned by differences in cultural orientations differ significantly from 
ordinary intergenerational tensions; (2) do predictors of intergener- 
ational conflict vary among diverse Hispanic ethnic groups and/or 



Cultural Factors in Mental Health Problems 43 



by social class level; (3) what are the systematic sources of accultura- 
tive stress that contribute to mental health problems among Hispanic 
adolescents; (4) are the risk factors for mental health problems, 
delinquency and drug abuse similar for Hispanic and non-Hispanic 
adolescents; and (5) which specific theories of adolescent psychologi- 
cal development are most useful for interpreting the effects of cul- 
tural factors on adolescents? 

Design of the Research 

The study described in this paper is known as the "South Florida 
Youth Development Project." The project commenced October 1, 
1990 and is supported by the National Institute of Drug Abuse 
(NIDA). The research site is Dade County (e.g., metropolitan Mi- 
ami), Florida, an area which has an estimated Hispanic population 
of approximately one million persons. This is a complex Hispanic 
population. About 60% of the total is of Cuban origin. The residual 
group includes a spectrum of Caribbean Basin, Central, and South 
American nationalities. Dade County also includes large African- 
American and non-Hispanic white populations, as well as various 
other non-Hispanic Caribbean ethnic groups such as Haitians, 
Jamaicans and Bahamians. This polyglot of ethnic varieties, which 
encompasses all socioeconomic strata, provides an excellent context 
for multi-cultural research. 

The study design can be summarized as follows. All male students 
entering either a middle school or junior high school in Dade County 
were asked to participate in the study. The Dade County School Dis- 
trict is the fourth largest unified system in the nation. There are an 
estimated 10,000 adolescent boys attending fifty different schools 
in the county. The boys in the sample are between 1 1 and 14 years 
of age when they entered the study, and because of this young age, 
few if any of the male adolescents of interest had dropped out of 
school or had experienced conduct problems serious enough to war- 
rant their referral to the criminal justice system. The study is lon- 
gitudinal in design and called for interviewing those in the sample 
once annually for three years. It was anticipated that approximately 
7,000 to 8,000 students would participate in the first wave of the 
study and that there would be an attrition rate of about 40% over 
the entire course of the research. Non-participants consisted primar- 
ily of students for whom parental consent was not obtained, or who 
were absent at the time the questionnaires were administered, and 
who migrated to areas beyond the Miami-Hialeah and Fort Lauder- 
dale consolidated Metropolitan Statistical Area (CMS A). Table 1 



44 Latino Mental Health 



contains information on the multi-wave design including data on an- 
ticipated attrition. 

Extensive research has indicated that self-reports of children 
regarding their mental health status are not always indicators of their 
mental health functioning or behavior problems (Achenbach, 1985). 
Therefore, we planned for parent and teacher collateral reports for 
a random subsample of 3000 participants, to be obtained for all three 
waves of the study. The adolescents and teachers were given ques- 
tionnaires; and the parents were interviewed either by telephone or 
in face-to-face situations. The primary instrument for determining 
mental health problems among those in the sample is the Child Be- 
havior Checklist (CBCL) (Achenbach, 1983). The Parents and 
Teachers Report Form was employed as part of the collateral phases 
of the study (Achenbach, 1986). These instruments were intended 
to identify problems and competencies manifested in differing do- 
mains of life activity which require differing interpersonal skills, role 
performance, and emotional maturity. As noted by Achenbach et 
al. (1990), childhood disorders cannot be fully understood on the 
basis of observations in only one environment or culture. Environ- 
mental contexts such as home versus school, the different interac- 
tion patterns present in these contexts, and differences between 
informants perspectives are all apt to contribute to the variations 
found between sources of data on children. 

The self-report questionnaire for the adolescent sample contains 
items to assess health status, including questions from the CBCL and 
the Center for Epidemiologic Studies-Depression Scale (CES-D) 
(Radloff, 1977). The adolescent questionnaire also contains sets of 
items designed to determine drug use, beliefs and behaviors, suici- 
dal ideation and behaviors, demographic characteristics, cultural and 
acculturation factors, self-esteem, perceived social supports, family 
functioning, and perceptions of deviancy of self and friends. In ad- 
dition, the school system provided information about academic per- 
formance and conduct problems for all those in the student sample. 
The multi-ethnic nature of the sample logically calls for the compara- 
tive analyses of risk factors for mental health problems among differ- 
ent ethnic subgroups. It was anticipated that approximately 50% of 
the sample would be Hispanic, 27% would be African-American 
and/or other Caribbean black origin groups, and 23% would be 
non-Hispanic whites. One of our analytic goals is to predict the fu- 
ture rates of mental health and drug use problems among different 
subgroups from the risk factors we will identify. This approach will 



Cultural Factors in Mental Health Problems 



45 



Table 1. Sample Selection/Follow-up 



CONSENT 
REQUESTED 



Students 
N= 10,000 



TIME1 
Baseline 
Participants 

— > 3,000 
Parents 



> 



> 



7,000 - 
Students 

3,000 - 

Teacher 

Ratings 



TIME 2 

Participants 



2,400 
Parents 



> 



5,600 - 
Students 

2,400 - 

Teacher 

Ratings 



TIME 3 

Participants 



-> 1,920 
Parents 

-> 4,480 
Students 

-> 1,920 
Teacher 
Ratings 



be useful in its own right, and it will also allow us to determine the 
reliability of the findings reported by Lewinsohn et al. (1988). They 
have reported from their prospective study of non-Hispanic white 
adolescents that most mental health problems emerged during junior 
high school and that the lifetime prevalence of psychiatric disorders 
in this group did not increase appreciably thereafter. Parenthetically, 
a recent Florida state-wide survey of drug use in middle and high 
schools has indicated that the life-time prevalence rates for smok- 
ing, alcohol use, and marihuana use were similar in middle schools 
and high schools (Statewide Florida Survey, 1988). 

Several process theories of deviance, drug use, and mental health 
problems will also be tested. For example, Kaplan's theory of self- 
derogation posits that people characteristically behave so as to 
minimize the experience of self-rejecting attitudes and to maximize 
the experience of positive self attidudes (Kaplan et al., 1986, 1987). 
This is a transactional model which assumes that when adolescents 
experience self-rejection they are motivated to alter the interpersonal 
circumstances responsible for these feelings. This approach assumes 
that in most instances adolescents will be responding to the evalua- 
tions of their parents and that when these are negative they will 
respond to them by either exhibiting more acceptable behaviors, or 
by rejecting their parental definitions in favor of those offered by 
their peers. When the latter occurs, it is hypothesized that those in- 
volved will redefine themselves in ways consistent with their primary 
reference group expectations, a process that often involves familial 
conflict. Using this theoretical framework, itis possible to introduce 
other explanatory factors, such as intergenerational acculturative 



46 Latino Mental Health 



conflicts and environmental acculturative stressors into the develop- 
ment of an explanatory model. 

The use of theories such as the self-derogation model also facili- 
tates direct comparisons between and among different ethnic and 
racial groups. These comparisons will reveal whether etiologic 
processes appear to be similar across cultures, and/or whether 
specific psychosocial or cultural factors significantly modify the 
explanatory model being used to guide our research. A persistent in- 
ability to change feelings of being devalued is believed to be as- 
sociated with familial conflict and rejection, depression, suicide, 
conduct problems, the selection of deviant peers, as well as substance 
abuse. 

In order to incorporate these various research objectives into an 
operational model that lends itself to latent variable structural anal- 
ysis, the integrative framework in Figure 1 will be used to facilitate 
this process. This framework provides a basis for formulating 
hypotheses which will be tested to determine the independent and 
interactive effects of latent variables net of measurement error. The 
theoretical model guiding these focuses on the social psychological 
stress process. Moreover it presupposes multiple casual paths, mul- 
tiple outcomes, and non-recursive relationships among the various 
explanatory factors. This type of model facilitates multistage 
analytical procedures for hypothesis and theory testing. It includes 
canonical correlations, confirmatory factor analyses, and Grade of 
Membership analysis (GOM) which creates latent classes based on 
important explanatory factors such as acculturative stress or cultural 
orientation (Manton et al., 1986). 

Issues of Measurement and Taxonomy 

The assessment of child and adolescent psychopathology is still 
in its early stages of development. Efforts to design and test instru- 
ments for use with pre-adult populations have included those of 
Achenbach et al. (1990) and Edelbrock and Costello (1988). The the- 
oretical and methodological assessment issues of child/adolescent 
mental health problems among Hispanics have been pioneered by 
Bird et al. (1988a, 1988b) in Puerto Rico. As in adult psychiatric 
epidemiology, two major types of measurement instruments have 
emerged. One of these focuses on the making of DSM-IIIR type di- 
agnosis. The Diagnostic Interview Schedule for Children (DISC) is 
now being refined for use in a series of community studies in the 
United States (Costello, 1985). This is a fully structured instrument 



Cultural Factors in Mental Health Problems 



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48 Latino Mental Health 



which requires the presence of a certain number of symptoms and 
exclusions, which are judged within the context of their recency, 
duration and severity. This "standardization" of the DISC may be 
premature given the relatively meager knowledge currently availa- 
ble regarding cross-cultural differences in mood, thought, and be- 
havioral disorders among children. Achenbach et al. (1990) have 
cautioned researchers/scholars on this issue by emphasizing that 
"cultural differences in language, child rearing customs, education, 
social standards, diet, stress, coping strategies, and opportunities 
may affect the prevalence of disorders and the form they take, and 
what is done when a disorder is deemed present" (Achenbach et al., 
1990, p. 84). 

In our opinion, the DSM-IIIR diagnostic categories on which the 
DISC is based can be viewed at present as preliminary and heuris- 
tic concepts. The validity and reliability of the DISC has not yet been 
sufficiently established, particularly as it relates to Hispanic and 
other ethnic populations in the United States and elsewhere. 

Currently, important development work has been conducted on 
the DISC, in order to have a version available for multi-site, col- 
laborative epidemiologic surveys in the United States. It will be 
several years, however, before the validity and reliability of the DISC 
as a method for case ascertainment among children and adolescents 
can be empirically established. Futhermore, the "present-absent" 
nature of all DSM-IIIR type diagnostic case ascertainment imposes 
serious limitations on basic epidemiologic field studies since ex- 
tremely large samples are needed to generate enough cases to deter- 
mine the prevalence and/or incidence of the various disorders, and 
concurrently one cannot determine, definitively, the validity and 
reliability of the findings if they are based on a small number of 
cases. These problems are exacerbated when one attempts to extrapo- 
late either the findings or the case identification procedures to popu- 
lations other than the ones surveyed. The implications of these 
conclusions are self-evident when one is interested in determining the 
prevalence of mental health problems among ethnic and racial sub- 
groups, especially when cultural differences are profound. 

An alternative approach to the measurement of child and adoles- 
cent mental disorders is to use empirically derived symptom and be- 
havior scales such as the CBCL (Achenbach & Edelbrock, 1981). 
These measures are empirically derived by conducting an exhaustive 
inventory of mood, ideational, and conduct reports from clinicians, 



Cultural Factors in Mental Health Problems 49 



counselors, teachers, parents, and others who treat or care for chil- 
dren and adolescents. This exhaustive list is then reduced by eliminat- 
ing all items that are not mentioned by at least 5% of raters. The 
resulting checklist (the CBCL in this instance) is then validated with 
clinically referred and non-referred children. The results of these va- 
lidity studies have shown conclusively that disturbed children can be 
reliably identified. Moreover, scales such as the CBCL can be used 
either as a continuous measure or to determine the presence or ab- 
sence of syndrome/disorders. The use of continuous measures have 
obvious analytic advantages not shared by procedures which produce 
categorical data only. 

As previously mentioned, the CBCL and similar instruments have 
the advantage of multiple observer ratings made by individuals who 
have observed the child functioning in a variety of different environ- 
ments including home and school. Futhermore, the approach has ad- 
vantages for use in cross-cultural research since those making the 
ratings will be applying culturally relevant criteria as they make their 
assessments. 

The problems of cross-cultural validity is substantially mitigated 
by the use of the CBCL because the mental health problems can be 
confirmed by teacher/parent judgements and the cut-points on the 
subscales can be set to reflect differences in cultural behaviors. In 
essence, the CBCL is more likely to be empirically grounded than 
instruments like the DISC because it does not impose cultural 
parameters on the symptoms and behaviors being assessed. Rather, 
the naturally occurring symptoms in a population are allowed to de- 
fine the clinically salient syndromes. The scale score comparisons can 
also be used for making intra-ethnic and inter-ethnic comparisons 
in several ways. Total scale scores, broad and narrow-band syn- 
dromes, discrepancies between raters, and covariation with other 
heuristically meaningful outcomes, such as drug use and deviance 
levels, can be empirically analyzed. 

For example, in a recent paper by Achenbach et al. (1990), adoles- 
cents in both Puerto Rico and the U.S. mainland reported more 
problems than were reported for them by their parents or teachers; 
although Puerto Rican adolescents reported fewer symptoms than 
their mainland counterparts, the Puerto Rican parent and teacher 
raters reported more problems and fewer competencies than the 
mainland parents did for their children. Moreover, the researchers 
concluded that the CBCL validity identifies problem children who 



50 Latino Mental Health 



have been referred in both populations. Different clinical cutoff 
points are probably needed, however, for valid cross-cultural assess- 
ments. For these reasons, the CBCL has been included in the 
research discussed in this paper because it offers more flexibility for 
studying mental health problems cross-culturally than the DISC at 
this point in time, and it is a more pragmatic tool for screening large 
scale community samples, especially when the protocol must be self- 
administered or when large numbers of other variables must be in- 
cluded in the questionnaire/interview schedule. 

There are some important similarities in the syndromes identified 
by the DISC and the CBCL. Achenbach and Edelbrock (1981) have 
identified the DSM-IIIR disorders that have correlation with specific 
CBCL syndromes (Achenbach, 1983). These are shown in Figure 2. 
Beyond these disorders, the CBCL, as well as other items and scales 
we used, obtain information about depressions, in addition to 
enough data on drug use, including alcohol and tobacco to make 
some DSM-IIIR type diagnostic judgements. 

Epidemiologic research on mental health problems among popu- 
lations of Hispanic adolescents is rare. The most outstanding exam- 
ple is the recent survey conducted by Bird et al. (1988a) in Puerto 
Rico. This research has provided the first opportunity to compare 
the levels of psychological, emotional, and behavioral problems in 
a population of Hispanic children with non-Hispanic children liv~ 

Figure 2. Approximate Relations Between DSM-IIIR and 
Empirically-Derived Syndromes 

DSM-IIIR CBCL TRF 

Solitary Agressive Aggressive Aggressive 

Conduct Disorder 
Oppositional Defiant 

Disorder 

Group Delinquent Delinquent Delinquent 

Conduct Disorder 

Attention Deficit- Hyperactive 

Hyperactivity Disorder Nervous-Overactive 

Overanxious Disorder Anxious-Obsessive 

Schizoid-Anxious 



Adapted from T. Achenbach and Craig Edelbrock: Manual For The Child Behavior 
Checklist. Burlighton, Vt., University of Vermont 



Cultural Factors in Mental Health Problems 5 1 



ing in the United States. A diagnostic protocol, the DISC and two 
empirical measures, the CBCL and the Global Assessment Scale 
(GAS) were employed. This excellent study was, however, only 
descriptive in character. As a consequence, the findings share the 
limitations of all descriptive research. Moreover, to date, there have 
been no carefully controlled analytic studies of Hispanic adolescents 
residing in the continental United States. Indeed, few are available 
for any ethnic or racial population. Therefore, our prospective study 
is an unusual opportunity to contribute to our understanding of the 
developmental processes and their linkage to mental health problems 
among children/adolescents with markedly differentethnic, racial, 
and cultural backgrounds. 

Cultural and Social Adjustment 

The mental health aspects and implications of cultural change and 
adaptation to new social environments have been extensively 
described in the social psychiatric literature (Mezzich & Berganza, 
1984; Portes & Rumbaut, 1990; Kuo, 1976; Fabrega, 1969; Vega et 
al., 1987). Nevertheless, the mechanisms involved in the psycholog- 
ical transitions from one culture to another and the effects of the 
changes on personal functioning and social adaptation of those af- 
fected remain enigmatic. Despite a formidable body of literature on 
the hypothesized social, psychological, and emotional challenges 
posed by immigrant/migrant adjustment to new social environ- 
ments, little empirical research has been reported on the effects of 
social adaptation and acculturation on mental health status, and em- 
pirical information focusing on children is virtually nonexistent. 

To date, the conceptualization and measurement of cultural ad- 
justment has focused almost exclusively on cultural orientation. In 
other words, primary attention has been given to the anchoring of 
individuals within a continuum of attitudes, values, and behaviors 
representing two presumably discrete cultures. Culture is a diffuse 
and complex concept, and it is extremely difficult to circumscribe 
conceptually. Cultural differences are more often a question of nu- 
ance than of stark contrasts. Nevertheless, although researchers in 
this field have recognized the multidimensional character of culture 
and the complexities of the acculturation process, measures of ac- 
culturation have tended to be unidimensional scales which locate an 
individual, or subgroup, along a continuum between hypothetically 
discrete cultural endpoints (Padilla, 1980; Cuellar et al., 1980; 



52 Latino Mental Health 



Szapocznik et al., 1987; Montgomery & Orozco, 1984; Marin & 
Sabogal, 1987). Using this approach, acculturation has been mea- 
sured in large field surveys and then used as an independent variable 
to predict health and mental health status, e.g., the Hispanic Health 
and Nutrition Examination Survey (Hanes) (Mosicki et al., 1989), 
and the Los Angeles Epidemiologic Catchment Area Project (EC A) 
Burnam et al., 1987). 

Szapocznik et al. (1978) reported on the development of a linear 
acculturation measure which focuses on values and behaviors among 
Cubans in Miami. Using this approach, empirical tests have con- 
firmed that acculturation in this population was a function of ex- 
posure, time, and gender. Young males with a significant time in 
country were found to have the highest rate of acculturation, fol- 
lowed by young females, then by their parents. Futhermore, this 
same group of researchers has also reported a direct relationship of 
disjunctures in values between parents and male children and inter- 
generational conflicts in the family. This process has been typified 
by an increase in the use of authoritarian and highly rigid parent- 
ing techniques in efforts to regain control of children. One of the 
outcomes of this approach has been the alienation of children and 
the rejection of parental values and lifestyles. Although much of this 
work is based on clinical observation and/or the use of small com- 
munity samples, the results are provocative and worthy of followup 
with carefully controlled comparisons of larger community samples. 

Other researchers have used unidimensional measures of accul- 
turation as indicators of psychological conflict among adults. For 
example, reflecting the logic of using Hispanic and Anglophone cul- 
tures as representing polar ends of a continuum, some researchers 
have divided the acculturation process into three stages: monocul- 
tural Hispanic, bicultural, and monocultural Anglo. Within this 
scheme, bicultural orientation is hypothesized to be the optimal 
mode of adjustment because it minimizes the personal alienation and 
estrangement from primary and secondary reference groups for 
those caught up in the acculturation process. It is hypothesized that 
bicultural adults are less prone to reactive stress disorders and that 
the bicultural family is less vulnerable to the intergeneration con- 
flicts, which produce stress for family members and for the family 
as a social system. Research results have tended to confirm these 
hypotheses. Bicultural individuals have been found to have lower 
rates of DSM-III type disorders than monocultural, "American" in- 
dividuals (Burnam et al., 1987). 



Cultural Factors in Mental Health Problems 53 



Although acculturation measures have both conceptual and 
methodological limitations, they also have heuristic and pragmatic 
value for research, and thus, were used in our present project. 
In doing so, we want to acknowledge several of the problems which 
limit their utility. First, as noted above, unidimensional accultura- 
tion models juxtapose cultures and presuppose that they are truly 
independent. However, this is not the case. Indeed, it may be just 
as accurate to hypothesize that Hispanic and Anglophone cultures 
are fundamentally similar. Frankly, no one has assumed the task of 
defining precisely how these cultures differ. Rather, cultural orien- 
tation has often been measured using behaviors which reflect be- 
havioral expectations of reference groups, or language preferences, 
rather than substantive culture commitments. 

Second, not all aspects of individual cultural orientation change 
uniformly with increased exposure to a new or dominant culture. 
Some types of behaviors may be easily learned and accepted but 
residual behaviors may endure, such as dietary habits, religious be- 
liefs and practices, or culturally conditioned cognitive patterns. In 
reality, the acculturation process is often very uneven and idiosyn- 
cratic. For example, Padilla and Keefe (1980) have reported that eth- 
nic loyalty, or attitudes and feelings about one's culture, descent and 
ethnic discrimination, tends to endure over time. However, one's 
cultural awareness, and/or the familiarity with the material and non- 
material aspects of one's culture, is more likely to erode over time. 

Third, there has been a tendency to confound the acculturation 
process with environmental stress and psychological conflict. For ex- 
ample, the term "acculturative stress", which is commonly used in 
the literature, engenders confusion by provoking the type of cause- 
effect tautology discussed by Lazarus and Folkman (1984). That is, 
it is unclear whether acculturative stress is a cause or an effect of psy- 
chological conflict, and moreover, the locus of acculturation stresses 
cannot be clearly delineated because they involve a large range of 
qualitatively distinct transactions between individuals and their en- 
vironments. Equating culture change with psychological dysfunc- 
tions often confounds the study of both. Thus, process models must 
be explicit about conceptual definitions and underlying relationships 
among independent, intervening and dependent factors. 

Procedures for Adolescent Acculturation 
Scale Development 

A central component of the pilot test for our longitudinal study 



54 Latino Mental Health 



was the development of valid and reliable measures of cultural orien- 
tation, acculturative-related stress, and commitment to cultural 
values among Hispanic adolescents. In order to illustrate our ap- 
proach, procedures we used for scale development and validation 
are summarized below. A four-step process was used to select the 
final items for the acculturation measure. We began with a list of 
initial items. A factor analysis was conducted followed by scale con- 
struction and reliability assessment and by tests for construct and 
criterion validity. Final item selection was then made. 

In the initial item choice phase, scales and items were assembled 
from various sources in the literature (Cuellar et al., 1980; Szapocz- 
nik et al., 1978; Marin & Sabogal et al., 1987; Rodriguez & Weis- 
burd, 1989). New items were also developed to assess the relevant 
domains of familism and acculturation-related stresses, such as those 
related to language problems. Items designed to determine choice 
of friends and school related behaviors and relationships with those 
in the non-Hispanic community were also selected. A questionnaire 
was then constructed and administered to 251 middle school boys 
and girls representing a wide range of Latin American nationalities 
and acculturation levels. 

In the second step, a series of factor analyses (principal compo- 
nents analysis with varimax rotation) were conducted based on the- 
oretical considerations and the results of previous research. We 
conducted factor analyses of items grouped first by content area; i.e., 
language, cultural orientation, acculturation-related stress, familism, 
and cultural values. Then our analyses were conducted by source of 
the scale items. For example, Szapocznik's items were analyzed 
together. We relied most heavily on the results of the factor analyses 
grouped by content area (i.e., theoretical construct). We relied 
on the other analyses when the results of the theory-based factor 
analyses were ambiguous. Factors with eigenvalues of 1.0 or higher 
were retained as meaningful, and variables with loadings of 0.50 or 
higher were retained as indicators of the construct being measured. 

In the third step, items on each factor were summed to form scales 
representing each construct. Alpha coefficients were calculated for 
each scale, and alphas were computed as well for each scale minus 
those items with the lowest factor loading. 

In the fourth step, the construct validity of each of the individual 
component items in each scale, as well as all of the scales, was as- 
sessed by comparing (using T-tests) those who completed the ques- 



Cultural Factors in Mental Health Problems 



55 



tionnaire in Spanish with those who completed it in English. Then 
the results derived from those who were born in Cuba, or Central 
or South America, were compared (again using T-tests) to those born 
elsewhere. Finally, the responses to individual items and the over- 
all scales were correlated with the length of time in the U.S. This 
procedure is illustrated in Table 2. 

We found that a preference for English and its use with friends 
and at school were positively correlated with being born in the U.S., 
and with taking the questionnaire in English, as well as to longer U.S. 



Table 2. Validating Comparisons for Acculturation Scales 





Comparison Variable 

LANGUAGE HISPANIC 
VERSION BORN 


HOW 
LONG 

INU.S. 


Language 


E>S*** 




A>H*** 


.636*** 


Media Use 


E>S*** 




A>H * 


433 *** 


Language 

Media 


E>S*** 




A>H*** 


.678*** 


Familism 


S>E*** 




H>A*** 


— .445 *** 


Cultural 
Values 


E>S ** 







219 *** 


Family 

Acculturation 

Conflict 








.033 


Ethnic 
Loyalty 


— 







.020 


Language 

Related 

Conflict 


S>E*** 




H>A ** 


- .496 *** 


Ethnic 
Awareness 










-.066 



Note: * < .05 
** < .01 
*** < .001 



E = English version 
S = Spanish version 
H = Hispanic born 
A = American born 



56 Latino Men tal Health 



residence if born in Latin- America. The preference for English lan- 
guage media had similar positive correlations with the language ver- 
sion of the questionnaire used and with nativity and time in country 
as well. For the "familism" component, a lower score indicated a 
higher degree of importance placed on the family. As expected, "low 
familism" was associated with use of the English language version, 
U.S. nativity, and more years in country. Family Acculturation Con- 
flict, Ethnic Loyalty, and Ethnic Awareness were factors not as- 
sociated with the validating variables listed in Table 2, but they were 
retained because of their theoretical significance. Language Related 
Conflict scores were positively related to taking the questionnaire 
in Spanish, as well as to being born in Latin America, and they were 
negatively related to length of time in country. Items or scales as- 
sessing language, cultural orientation, and cultural values which were 
not correlated in the hypothesized direction with any of these exter- 
nal criteria were excluded from further consideration. 

For purposes of inclusion in a longitudinal study on the predic- 
tors of psychopathology, deviant behavior, and drug use, we also 
assessed the criterion validity of the scales, i.e., the extent to which 
cross-sectionally, they were related with deviant behavior and/or 
drug use. This analysis is illustrated in Table 3. 

All acculturation scales were correlated with scales of deviant be- 
havior, drug use and perceived friend's drug use. When deciding 
upon leaving individual items in scales or removing them when the 
internal consistency analyses were ambiguous, only those items were 
retained which had high correlations to the criterion variables. 

In the last step, final item selections were made. We were limited 
to the selection of 20-25 items due to space, time, and subject bur- 
den considerations. Scales were chosen whose alpha coefficients were 
at least moderate, 0.5 or higher, and/or which had significant and 
strong relationships with variables indicating acceptable construct 
validity. The composition of scales and their alpha coefficients are 
presented in Table 4. 

Conclusion 

The current decade will undoubtedly see exciting new research on 
Hispanic adolescents, including prospective studies such as the one 
described in this paper. As previously indicated, numerous issues 
related to the conceptualization and measurement of psychiatric dis- 
orders and acculturation remain, and these provide a challenging 



Cultural Factors in Mental Health Problems 



57 



Table 3. Correlations Between Acculturation Scales and 
Criterion Variables 





DEVIANT 
BEHAVIOR 


Comparison Variables 

DRUG PERCEIVED 

USE FRIEND DRUG USE 


Language 


.250*** 


j 47 *** 


.133 * 


Media Use 


.225 *** 


.110 * 


.088 


Language 
Media 


.288*** 


.151 ** 


.107 * 


Familism 


-.080 


-.119 * 


-.046 


Cultural 
Values 


"302 *** 


.302*** 


.227 ** 


Family 

Acculturation 

Conflict 


326 *** 


19g *** 


.100 


Ethnic 
Loyalty 


245 *** 


.045 


.092 


Language 

Related 

Conflict 


-.074 


-.113 * 


-.002 


Ethnic 
Awareness 


.054 


-.039 


.010 



Note: * < .05 
** < .01 
*** < .001 



research agenda. Certainly no single study can address all of them. 
Nevertheless fundamental questions about cultural adaptation and 
adolescent development and their relationships to mental health and 
social functioning can now be examined within comprehensive the- 
oretical paradigms. And by using prospective study designs, one is 
able to develop causal models employing latent variable analytical 
techniques. In short, we can begin to explore many longstanding sup- 
positions and beliefs concerning cultural values and conflicts and 
to determine their role in offsetting or increasing the psychological 
and emotional vulnerability of Hispanic adolescents residing in 
South Florida. 



58 Latino Mental Health 



Table 4. Scale Items and Alphas 

Language Behavior: (alpha = .817) 

What language do you prefer to speak? 
What language do you speak at school? 
What language do you speak with friends? 
Media Use: (alpha = .663) 

In general, in what language are the movies, T.V. and radio programs 

you like to watch and listen to the most? 
What kind of music do you listen to? 
Language media: (alpha = .857) 

What language do you speak at school? 
What language do you speak with friends? 
What language are the magazines you read? 
How much do you enjoy English language magazines? 
Familism: (alpha = .698) 

If someone has the chance to help a person get a job, it is always better 

to choose a relative rather than a friend. 
When someone has serious problems, only relatives can help. 
When looking for a job, a person should find work near his parents, 
even if that means he loses a good job somewhere else. 
Cultural Values: (alpha - .533) 

How important do you think it is to respect your parents' wishes even 

if you disagree with them? 
How important do you think it is to avoid doing anything that could 
embarrass your family? 
Family Acculturation Conflict: (alpha = .613) 

How often have you had problems with your family because you 

prefer American customs? 
How often do you get upset at your parents because they don't know 
American ways? 
Ethnic Loyalty: (alpha = .633) 

How often do you feel that you would rather be more American if you 

had a choice? 
How often do you feel uncomfortable having to choose between Non 
Latin and Latin ways of doing things? 
Language Related Conflict: (alpha = .623) 

How often has it been hard for you to get along with others because 

you don't speak English well? 
How often has it been hard to get good grades because of problems 
in understanding English? 
Ethnic Awareness: (alpha = .510) 

How often do people dislike you because you are Latin? 

How often are you treated unfairly at school because you are Latin? 

How often have you seen friends treated badly because they are Latin? 



Cultural Factors in Mental Health Problems 59 



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in Cuban mothers. In C. Monteil (Ed). Hispanic families (41-65). 
Washington, D.C.: COSSMHO 

Szapocznik, J.; Scopetta, M.A.; Kurtines, W. and Aranalde, M. A. (1978). 
Theory and measurement of acculturation. Inter-American Journal of 
Psychology, 12, 113-130. 

Vega, W.; Hough, R.L. and Romero, A. (1983). Family life patterns 
among Mexican- Americans. In G. Powell et al. (Eds). The Psychosocial 
development of minority group children (194-215). New York: 
Bruner-Mazel. 

Vega, W.A.; Hough, R.L. and Miranda, M.R. (1985). Modeling cross- 
cultural research in Hispanic mental health. In W. Vega and Miranda 
(Eds), Stress and Hispanic mental health (1-29). Rockville, Maryland: 
NIMH. 

Vega, W.A.; Kolody, B. and Valle, J.R. (1987). Migration and mental 
health. An empirical test of depression risk factors among Mexican 
women. International Migration Review, 21, 512-529. 



4 



Hispanic Immigration and 

Socioeconmic Status: A Review of 

Psychiatric Epidemiologic Findings 

Cynthia A. Telles, Ph.D. 



The relationship of immigration to mental health has been the 
subject of much interest and debate in the literature. A lack of con- 
clusive empirical evidence is not surprising given the enormous com- 
plexity of this relationship. Not only is the accurate measurement 
of the mental health correlates a formidable task, but Hispanic im- 
migration, itself, is a function of a dynamic and complex interplay 
of international economic and sociopolitical forces. As such, it is a 
multifaceted and continuously changing phenomenon whose 
parameters are difficult to estimate. Nonetheless, it is possible to dis- 
cern some patterns of significant relationships, which begin to 
emerge on the basis of cumulative evidence provided by recent 
epidemiologic studies and of an understanding of their apparent dis- 
crepancies. Though these studies do not yield prospective data, which 
directly measure casaul effects, some preliminary inferences can be 
made from cross-sectional comparisons of Hispanic subpopulations 
by immigrant status and generational level. 

The voluminous literature on the relationship of immigration and 
psychiatric disorder in the general population of the United States 
has been reviewed by others (Favazza, 1980; Locke, 1960; Malzberg 
& Lee, 1956; and Murphy, 1961). Earlier studies generally asserted 
that immigrants to the United States compared to natives were more 
likely to have mental disorder (Murphy, 1961); however, later studies 
which controlled for sex and age found few differences. Important 
to note is that most of this early research was based on hospitaliza- 
tion rates with limited generalizability. On the other hand, the 
midtown Manhattan study, which utilized a large survey with a com- 
munity population, reported that immigrants who arrived in the U.S. 
before 1922, prior to the enactment of restrictive immigration laws, 
had higher rates of mental disorders compared to natives. Yet there 
were no significant differences between immigrants after 1922 and 



64 Latino Mental Health 



natives (Srole, Langer & Michael, 1962). Among the most common 
explanations for the relationship between immigration and psy- 
chiatric disorder is the selection theory, which proposes that a 
pre-existing disorder increases the probability of migration. Other 
investigators, however, have interpreted their findings to suggest that 
the stress of the migration experience precipitates the onset or con- 
tributes to the incidence of disorders among immigrants. 

Compared to the general literature on the psychiatric epidemiol- 
ogy of immigration, there has been a paucity of empirical data fo- 
cused on Hispanics. More recently, however, a few significant studies 
have been conducted which identify some mental health correlates 
of Hispanic immigration status. Among the most noteworthy are 
those conducted by Vega and his associates. Vega, Warheit & Mein- 
hardt (1983) conducted an epidemiologic field survey using the 
Health Opinion Survey and measures of psychiatric symptomatol- 
ogy for the purposes of identifying high risk groups in Santa Clara 
County. The sample of 1342 adults consisted of recent Mexican im- 
migrants, as well as more acculturated Mexicans and second gener- 
ation Mexican- Americans and Anglos. Overall, the Mexican origin 
group had higher symptomatology and dysfunction levels than 
Anglos, with the monolingual, Spanish-speaking migrants exhibit- 
ing significantly greater symptomatology. 

Important to note is that the scores of the second generation sub- 
sample were significantly lower than those of the Mexican im- 
migrants. In fact, after controlling for socioeconomic status, the 
scores of the second generation Mexican- Americans were more simi- 
lar to those of the Anglo subsample. The author concludes that im- 
migrant status and length of time in the United States were associated 
with the severity of symptomatology. 

The relationship of immigrant status to mental health status is very 
complicated and confounded by socioeconmic status. The Spanish- 
speaking immigrants had lower educational levels than all other sub- 
samples. In fact, after controlling for ethnicity, age and sex, the data 
strongly suggest that socioeconomic factors are better predictors than 
ethnicity of depressive symptomatology. Thus, immigrants appear 
to be at risk, not only because of the stressful experiences associated 
with migration, such as multiple losses, language and culture bar- 
riers, discrimination, etc., but even more importantly, because of the 
chronic strain associated with economic deprivation. 

An extensive survey conducted by Vega and research associates 



Hispanic Immigration and Socioeconomic Status 65 



(Vega, Valle, Kolody & Hough, 1985) produced the most significant 
sample of immigrants in a cross-sectional study of depression in the 
United States. The sample consisted of a cohort of 2157 Mexican 
women who were immigrants in San Diego County. The most 
striking finding was the excessively high prevalence of depressive 
symptoms as reflected by a grand mean of 15.71 on the Center for 
Epidemiologic Studies-Depression Scale (CSE-D), given that 16 is 
the customary cutpoint. Almost 42% of the Mexican descent group 
met the case criteria. As discussed by Vega, et al. (1985), this preva- 
lence is in sharp contrast with those yielded by surveys of the general 
Anglo-American population usually ranging between 17% and 20%. 
Among the statistically significant risk factors is the duration of resi- 
dence in the U.S. with those reporting five or fewer years having the 
highest mean scores and caseness rates. The data clearly suggest that 
more recent immigrants are experiencing more stress induced sym- 
ptoms. Additionally, lower level of education (<5 years), lower in- 
come ( < $600 a month ) and disrupted marital status were significant 
predictors of depressive symptomatology. In fact, income had 
greater predictive value than immigrant status. Thus, the results of 
Vega's study not only provided evidence of the distress associated 
with migration, but they also underscore the predominant contribu- 
tion of socioeconomic factors. 

Another cross-sectional field survey, which represents the first at- 
tempt to conduct large scale binational epidemiologic research, col- 
lected data on the prevalence of depressive symptoms among 1 ,000 
person in Tijuana, Mexico. Using the CES-D, Vega, Valle, Kolody 
and Hough (1986) found a depression caseness rate of 26.4%, which 
is high relative to rates among most U.S. populations but signifi- 
cantly lower than the rate of the Mexican female immigrant sample 
in San Diego. This comparison suggests that the higher scores among 
the latter group reflect the effects of stress associated with immigra- 
tion, in that the populations are ethnically similar and geographi- 
cally contiguous. It would be important, however, to partial out the 
effects of gender before making conclusive statements. Important 
to note again, is a similar pattern of risk factors, such as: lower so- 
cioeconomic status, disrupted martial status, unemployment, and 
poor health. Once again, the most powerful demographic variable 
in the prediction of depressive symptoms was socioeconomic status. 

The significant contribution of socioeconomic factors to the 
prediction of depressive symptomatology is confirmed by the results 



66 Latino Mental Health 



of other epidemiologic studies conducted in the United States. Bur- 
man, Hough and Timbers (1983) compared symptoms of psycho- 
logical distress among Anglos, Mexican- Americans, Mexicans raised 
in Mexico but living in El Paso, and Mexicans living in Mexico. As 
compared to Anglos, the Mexican origin groups reported more se- 
vere symptomatology associated with psychological disturbance. 
Controlling for the effects of socioeconomic status, however, 
reduced the differences between the four groups. The authors con- 
clude that the ethnic differences associated with psychiatric distur- 
bance were mostly a function of socioeconomic status. No significant 
differences were found among Mexican- Americans raised in Mex- 
ico and those raised in the United States. 

Two other surveys of U.S. Hispanic populations fail to analyze 
the status of immigrants; however, the surveys do underscore the im- 
portance of socioeconomic status as a predictor of depressive symp- 
tomatology. Frerichs, Aneshensel & Clark (1981) conducted a 
community survey using the Center for Epidemiologic Studies- 
Depression Scale (CES-D) on a multi-ethnic probability sample of 
1,002 in Los Angeles County, California. The prevalence of depres- 
sion was greatest among Hispanics and least among Whites, with 
Blacks and other groups reporting intermediate rates. Furthermore, 
females were twice as likely to be depressed as males. After control- 
ling for selected demographic and socioeconomic variables, the eth- 
nic differences were not significance. The results are interpreted as 
suggesting that economic strain experienced by ethnic minorities is 
significantly related to higher rates of depression for Hispanics. 

Roberts (1980, 1981) presented data from two surveys conducted 
in Alameda County, California, between 1973 and 1974, which sug- 
gest that Mexican-Americans have rates of psychological disturbance 
at least as high as those of Anglos, and that the prevalence of depres- 
sion may be higher than it is in other groups. Roberts (1984) con- 
cluded, after further analysis of the data, that, both in terms of mean 
scores and "caseness", Mexican-Americans reported significantly 
higher levels of distress. After controlling for the joint effects of edu- 
cation and income, however, the ethnic difference in mean CES-D 
scores became non-significant. 

The lifetime prevalence of eight major DSM III (Diagnostic 
Statistical Manual III) disorders was examined as a function of 
acculturation and immigrant/native status in a large household 
sample of adults of Mexican ethnic origin (Burnam, Hough, Karno, 
Escobar & Telles, 1987). The data were collected by the Los Angeles 



Hispanic Immigration and Socioeconomic Status 67 



Epidemiologic Catchment Area Survey, one of the five field studies 
which composed the collaborative National Epidemiologic Catch- 
ment Area Program (E.C.A.). The E.C.A. was initiated by the Na- 
tional Institute of Mental Health to provide the first estimates of the 
prevalence and incidence of psychiatric disorders based on large-scale 
epidemiologic surveys in the United States. The Los Angeles study 
focused on a comparison of the Hispanic and non-Hispanic popu- 
lations with a total sample of 3,132 adults who were directly inter- 
viewed. The methodological details have been described previously 
(Burnam, Hough, Escobar, Karno, Timbers, Telles & Locke, 1987). 
This study of acculturation and immigrant status extends previous 
work by examining specific diagnosable psychiatric disorders rather 
than symptoms in a large and diversely acculturated household 
sample. 

The purpose of the analyses to be reported was to examine the 
relationship of acculturation to lifetime prevalence of specific psy- 
chiatric disorders and to determine whether the association between 
prevalence could be completely or partially explained by differences 
in immigrant/native status. Psychiatric disorder was based on DSM 
III criteria using the N.I.M.H. Diagnostic Interview Schedule 
(D.I.S.), a highly structured instrument designed to be administered 
during interviews by lay persons. Acculturation was assessed with 
a 26-item scale described by Burman, Telles, et al. (1987). The de- 
sign included a two-stage, area probability sample of 1,195 adults 
stratified by catchment area. 

Controlling for sex, age and gender, higher acculturation was as- 
sociated with higher lifetime prevalence rates of phobia, alcohol 
abuse/dependency, and drug abuse/dependency. Consistent with the 
acculturation findings, native born Mexican- Americans had higher 
prevalence rates of disorders compared to Mexican immigrants, in- 
cluding phobia, alcohol abuse or dependency, as well as major 
depression and dysthymia. After controlling for immigrant/native 
status, all significant relationships to acculturation were eliminated 
except for drug/dependency. Previous studies of immigration have 
confounded these variables. The results of this study suggest that the 
acculturation process may not directly influence risk for disorders 
among Mexican- Americans. It appears that immigrant Mexican- 
Americans have different risks for disorders than native Mexican- 
Americans for reasons that are partly unrelated to acculturation. 

Another more recent analysis of the Los Angeles E.C.A. data ex- 
amines immigrant status differences in acculturation, strain, social 



68 Latino Mental Health 



resources and social conflict to predict differences in depression, as 
measured by the CES-D between U.S. -born and Mexico-born per- 
sons of Mexican descent. Consistent with some of the aforemen- 
tioned E.C.A. data based on the D.I.S., U.S. -born Mexican 
Americans had higher CES-D depression scores than those born in 
Mexico. When social psychological variables (distress, social integra- 
tion, social support and conflict) were controlled in a multiple regres- 
sion analysis, the immigrant status difference persisted throughout. 
Interesting to note is that, in step two of the multiple regression when 
acculturation and immigrant status were controlled, more symp- 
tomatology was reported by the women, the younger respondents, 
the less educated and those with lower incomes. In step three, those 
with fewer relatives and the unmarried had higher symptom levels, 
and, in step four, economic strain and household strain were each 
strongly associated at the .001 level with depressive symptoms. In 
this analysis, immigrant status differences persisted even after con- 
trolling for all of the variables. 

In summary, a major factor affecting the prevalence of psychiatric 
disorder among Mexican- Americans is immigrant status. The 
authors interpret this finding to be partially the result of a selection 
process in which healthier individuals are more likely to immigrate 
and partially due to elevated rates of disorder among native Mexican- 
Americans because of frustrated status expectations (sense of rela- 
tive deprivation). Rates of certain disorders (e.g., substance abuse) 
also may be elevated due to spending developmental years in con- 
ditions of greater stress associated, not only with urban poverty, but 
with discrimination and cultural conflict in the context of less 
familial social support and extended support of various kinds. By 
cultural conflict I am referring to internal identity conflict, intra- 
familial conflict and conflict with the larger society. Additionally, 
earlier exposure to the socializing institutions, such as the school sys- 
tem, may account for some of these differences. In terms of drug 
abuse/dependency, there is greater availability and usage of drugs 
in the U.S. inner cities to which natives are differentially exposed 
at an earlier age. 

Compared to the aforementioned surveys, the Los Angeles E.C.A. 
study appears to yield conflicting evidence, in terms of the associa- 
tion of both immigrant status and mental health status. These dis- 
crepancies may be accounted for by differences in site characteristics, 
methodology and the nature of the psychological phenomena being 
assessed. Most of the E.C.A. data on Hispanics were collected 
from a catchment area, which contains a relatively high density of 



Hispanic Immigration and Socioeconomic Status 69 



Hispanics who comprise a well established and politically organized 
community. It appears that other surveys obtained samples with a 
proportionately greater number of recent immigrants and persons 
in lower levels of income and education. Furthermore, one could ex- 
pect that the distribution of respondents along the acculturation con- 
tinuum was different in the E.C.A. sample compared to the samples 
obtained in other surveys. 

Differences in data analysis may also account for some differences 
in the reporting of the relationship of acculturation and immigrant 
status to mental health status. For example, in the Vega et al. (1986) 
study, the association between more recent immigrant status and 
higher CES-D scores was only significant for the first five years fol- 
lowing immigration. In the E.C.A. analysis, immigrant status was 
treated as a dichotomous variable. Finally, it is important to note 
that the data reported in the E.C.A. study were collected with the 
Diagnostic Interview Schedule and data reported in most other 
studies were based on the CES-D. These instruments assess differ- 
ent psychological phenomena with the former yielding diagnosable 
psychiatric disorder and the latter providing information about 
symptoms of distress and demoralization that are more subject to 
situational stress. Additionally, from a methodological point of view, 
in comparing the E.C.A. protocol to those of other studies, the 
CES-D was administered as part of a very lengthy protocol after the 
Diagnostic Interview Schedule. It is unclear what biasing effect this 
difference may have produced. There is clearly a need for a more 
standardized analysis of various data sets using similar demographic 
controls. 

A review of these recent epidemiologic studies reveals an appar- 
ent discrepancy, in terms of the immigrant generation most at risk 
for the deleterious mental health consequences of immigration. It 
is important, however, to conduct further research which elucidates 
the meaning of these differences. For example, while immigrants 
may be at greater risk during the first few years after immigrating 
for symptoms of acute distress and demoralization associated with 
the interaction of immigration and poverty stressors, the subsequent 
acculturating generations may be at greater risk for developing 
psychiatric disorders, such as substance abuse/dependence, as a 
function of differential exposure to U.S. culture and socializing in- 
stitutions and other stressors associated with urban poverty, minority 
group status, culture conflict and a relative lack of social support 
during their early developmental years. 

More research in general is needed to tease apart these complex 



70 Latino Mental Health 



relationships. It will be important to partial out the effects of im- 
portant mediating variables from those directly related to the migra- 
tion experience. Among the variables related to the heterogeneity of 
the Hispanic immigrant population which affect psychosocial adap- 
tation are: (1) economic, social and educational status; (2) personal- 
ity adaptation and coping resources; (3) the extent to which the 
conditions motivating the migration were stressful (e.g., war, perse- 
cution); (4) the extent to which the migration was involuntary and 
unwanted (e.g., refugees); (5) the degree to which returning to the 
county of origin is not optional (e.g., exiles); (6) the degree to which 
the economic and sociopolitical conditions in the host country cre- 
ate an unfavorable climate for immigrants, particularly if not 
documented; and (7) the quality of the diplomatic relations between 
the governments of the donor and host countries and their effect on 
the receptivity toward immigrants, particularly refugees. 



References 

Burnam., M.A.; Hough, R.L.; Escobar, J.I.; Karno, M.; Timbers, D.M.; 
Telles, C.A. and Locke, B.Z. (1987). Six months prevalence of specific 
psychiatric disorders: Mexican- Americans and non-Hispanics whites in 
Los Angeles. Archives of General Psychiatry, 44, 687-694. 

Burnam, M.A.; Hough, R.L.; Karno, M.; Escobar, J.I. and Telles, C.A. 
(1987). Acculturation and life prevalence of psychiatric disorders among 
Mexican Americans in Los Angeles. Journal of Health and Social Be- 
havior, 28, 89-102. 

Burnam, M.A.; Telles, C.A.; Hough, R.L. and Escobar, J.I. (1987). Mea- 
surement of acculturation in a community population of Mexican 
Americans. Hispanic Journal of Behavioral Sciences, 9(2), 105-130. 

Burnam, M.A.; Timbers, D.M. and Hough, R.L. (1984). Psychological 
distress among Mexican-Americans, Mexicans and Anglos from two 
border cities. Journal of Health and Social Behavior, 25, 24-33. 

Favazza, A. (1980). Culture change and mental health. Journal of Oper- 
ational Psychiatry, 2(2), 101-119. 

Frerichs, R.R.; Aneshensel, C.S. and Clark, V.A. (1981). Prevalence of 
depression in Los Angeles County. American Journal of Epidemiology, 
113, 691-699. 

Locke, B.; Kramer, M. and Pasamanik, B. (1960). Immigration and in- 
sanity. Public Health Report, 75, 301-306. 

Malzberg, B. and Lee, E. (1956). Migration and mental disease. New York: 
Social Science Council. 



Hispanic Immigration and Socioeconomic Status 71 



Murphy, H. (1965). Migration and the major mental diseases. In M. Kan- 
tor (Ed.), Mobility and mental health. Springfield, Illinois: Charles C. 
Thomas. 

Roberts, R.E. (1980). Prevalence of psychological distress among Mexican 
Americans. Journal of Health and Social Behavior, 21, 135-145. 

Roberts, R.E. (1981). Prevalence of depressive symptoms among Mexican 
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Roberts, R.E. (1984). Minority status and psychological distress reexa- 
mined: The case of Mexican Americans. In J.R. Greenley (Ed.), 
Research in community mental health. Greenwich, Connecticut: JAI 
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Srole, L.; Langner, T. and Michael, S. (1962). Mental health in the 
metropolis: The midtown Manhattan study. New York: McGraw Hill. 

Vega, W.A. (1980). Defining Hispanic high-risk groups: Targeting popu- 
lations for health promotion. In R. Valle and W. Vega (Eds.), Hispanic 
natural support systems. Sacramento: California State Department of 
Mental Health. 

Vega, W.A.; Valle, J.R.; Kolody, B. and Hough, R. (1987). The Hispanic 
Social Network Prevention Intervention Study: A community-based ran- 
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Hemisphere. 

Vega, W.A.; Warheit, G.; Buhl-Auth, J. and Meinhardt, K. (1984). The 
prevalence of depressive symptoms among Mexican-Americans and An- 
glos. American Journal of Epidemiology, 592-607 '. 

Vega, W.A.; Kolody, B. and Hough, R.L. (1987). Depressive symptoma- 
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Vega, W.A; Kolody, B.; Valler, R. and Hough, R.L. (1987). Depressive 
symptoms and their correlates among immigrant Mexican women in the 
United States. Social Science and Medicine, 22, 646-652. 



Psychiatric Conditions Among 

Puerto Ricans: Are They More Prevalent 

Than In Other Ethnic Groups? 

Glorisa Canino, Ph.D. 



For years, psychiatric epidemiology studies have revealed distress- 
ing statistics suggesting that the prevalence of mental health problems 
among the Puerto Rican population in both the United States and 
the island is excessively high relative to that of other ethnic groups 
(Dohrenwend, 1986; Guarnaccia et al., 1990; Haberman, 1976; 
Strole et al., 1962;). Several methodological and substantive expla- 
nations have been given for this apparent high rate of mental dis- 
tress among our population, such as: (1) the majority of Puerto 
Ricans (both mainland and islanders) are socioeconomically disad- 
vantaged, rendering them vulnerable to mental disorders (Rogler et 
al., 1989); (2) the alienation and prejudice suffered by most Hispanic 
Americans, coupled with migration stress, also renders them vulner- 
able to mental distress; (3) most studies have used psychodiagnos- 
tic instruments which lack validity and cultural relevance (Malgady 
et al., 1987); (4) differences in response style and the use of differ- 
ent cultural connotations to desirable behavior (Dohrenwend & 
Dohrenwend, 1969) increases symptom reporting in our population. 

Studies of Island Puerto Ricans 

The vast majority of the above quoted epidemiological studies 
used symptom scales to determine psychiatric morbidity, and it re- 
mained unclear whether the higher rates were due to a true higher 
prevalence of psychiatric disorders among the Puerto Rican popu- 
lation, or whether the high rates of symptoms reflected cultural pat- 
terns of stress or distress. More recently psychiatric morbidity was 
ascertained using a diagnostic interview (Diagnostic Interview Sched- 
ule, DIS) which measured psychiatric disorders based on the Ameri- 
can Psychiatric Association Diagnostic Statistical Manual III (DSM 
III). Prevalence rates for island Puerto Ricans for most specific psy- 
chiatric disorders studied did not differ significantly from those of 



74 Latino Mental Health 



other ethnic groups (Canino et al., 1987a). Although the results of 
this study may seem contradictory to the vast majority of the pre- 
vious epidemiological studies, as Rogler et al. (1989) point out, it is 
possible that the conclusions of both types of studies are correct and 
that Puerto Ricans may indeed report more psychiatric symptoms, 
yet evidence DSM-III prevalence rates which are similar to those of 
other ethnic groups. Rogler et al. (1989) also point out that this in- 
terpretation is purely speculative and that future investigations with 
probability samples of Hispanics and non-Hispanics whites should 
include the administration of both symptom checklists and struc- 
tured interview schedules. 

We have recently attempted to answer empirically this speculation 
by comparing both rates of psychopathology and symptom levels in 
community samples of Hispanics and non-Hispanic groups from the 
Los Angeles Epidemiologic Catchment Area Study with island 
Puerto Ricans (Shrout et al., 1992). Hispanics from Los Angeles 
were further classified into those born in Mexico (immigrant 
Mexican-Americans) and those born in the United States (Native 
Mexican- Americans). The data from these analyses were obtained 
from the Los Angeles Epidemiologic Area Study (Karno et al, 1987) 
and the Puerto Rican adult epidemiologic survey (Canino et al, 
1987a). Both studies used probability population samples and the 
DIS to measure specific psychiatric disorders. Symptom levels were 
determined by empirically defined DIS symptom scales developed 
by Rubio-Stipec et al. (1990). The study is important because of the 
fact that differences in population rates of disorders or symptoms 
were accounted for by controlling for possible differences in sam- 
ple composition among the groups. That is, all statistical analyses 
controlled for sex, age, educational level, number of people in the 
household and zone of residence. This was considered essential since 
prevalence rates of psychiatric disorders have been found to vary in 
relation to the above demographic factors (Robins et al., 1985; 
Canino et al, 1987a). 

The results reported by Shrout et al. (1992) indicated that Mexican- 
American immigrants had the least psychiatric disorders and symp- 
tom levels as compared to all other ethnic groups. Puerto Ricans had 
lower prevalence rates of major depression and alcohol abuse and 
dependence but higher rates of somatization disorder and somatic 
symptoms. Anglos or Non-Hispanic whites, as well as Native 
Mexican-Americans, had higher rates of major depression, de- 
pressive symptoms, and alcohol abuse and/or dependence, but less 



Psychiatric Conditions among Puerto Ricans 75 



somatization, as well as somatic symptoms, compared to Puerto 
Ricans. 

How can we then explain the fact that these recent studies did not 
confirm prior research? Puerto Ricans did not exhibit (except for 
somatization) higher rates of psychiatric disorders or symptoms 
compared to other ethnic groups. If we examine the four explana- 
tions given previously for the supposed higher prevalence we may 
find the answer. First, in both the Puerto Rico and the Los Angeles 
studies, the psychodiagnostic instrument used was previously tested 
in the particular Hispanic populations (Burnam et al., 1983; Canino 
et al., 1987b;), thus reducing bias due to inadequate instrumenta- 
tion for the measurement of mental disorders in the population and 
precluding the possibility of response styles affecting the results. 
Second, the comparison of different Hispanic groups with Anglos, 
while at the same time controlling for socioeconomic, age and sex 
differences in the sample composition, reduced the likelihood that 
differences in prevalence rates could be explained by sample com- 
position. Finally, island Puerto Ricans are not subjected to the 
prejudice and alienation, or to the migration stress experienced by 
mainland Puerto Ricans or other minority groups. 

The results of the analyses reported by Shrout et al. (1992) also 
revealed that no particular ethnic group was at greater risk for psy- 
chiatric disorders in general. If anything, the immigrant Mexican- 
Americans were at less risk than any other group possibly because 
of a selective migration process. It is possible that "robust or 
healthy" Mexican- Americans are the ones who can successfully mi- 
grate to the United States (Burnam et al., 1987). Furthermore, the 
risk for disorders varied by specific psychiatric disorder or syndrome 
and by ethnicity. Of interest was the fact that Puerto Ricans only 
scored higher than the other ethnic groups in somatization disorder 
and somatic symptoms, a finding reported as well in other analyses 
of the same data set (Canino et al., 1987a; Escobar et al., 1989; 
Canino et al., 1992). 

Studies of Mainland Puerto Ricans 

But what about mainland Puerto Ricans? Are they at higher risk 
for mental disorders or distress as compared to other ethnic groups 
or to island Puerto Ricans? Recently, Guarnaccia et al. (1990) 
reviewed the literature of epidemiological studies of Puerto Rican 
mental health with particular emphasis on mainland Puerto Ricans. 
In this review, Guarnaccia et al. (1990) attempted to answer two 






76 Latino Mental Health 



main questions: Why do Puerto Ricans report more symptoms than 
other groups? and, Is the higher rate of symptoms a result of greater 
pathology or of response style? 

We have already provided evidence (Shrout et al., 1992) that island 
Puerto Ricans do not report higher psychiatric symptoms (except for 
somatization) compared to other ethnic groups. Furthermore, no evi- 
dence was found of a response style bias among this group. In con- 
trast, the evidence so far for mainland Puerto Ricans points towards 
an opposite trend. The results of Guarnaccia et al. (1990) indicated, 
that, for the most part, in most studies in which Puerto Ricans from 
the United States were compared to other ethnic groups, the latter 
reported higher rates of psychiatric symptoms or distress. Salient 
among all the studies quoted was a recent comparison of mainland 
Puerto Ricans with other Hispanic Americans. Moscicki et al., (1987) 
in analyzing the Hispanic Health and Nutrition Examination Sur- 
vey (HANES) data reported significantly higher rates of major 
depressive episode and depressive symptoms among New York 
Puerto Ricans compared to other Hispanic groups in the United 
States. These rates remained significantly higher even after control- 
ling for socio-demographic characteristics. The prevalence rates of 
major depressive episode among mainland Puerto Ricans were sig- 
nificantly higher (more than double) than those reported by Canino 
et al. (1987a) for island Puerto Ricans. Since the same diagnostic in- 
strument (DIS) was used in both the island and mainland study, 
differences in rates could not be explained by differences in either 
instrumentation or diagnostic criteria. This finding is particularly 
interesting, if we consider that Shrout et al. (1992) indicated that is- 
land Puerto Ricans had significantly lower rates of major depres- 
sion and depressive symptomatology, as compared to the other 
ethnic groups studied. 

Various factors could explain the higher rates of depressive symp- 
toms and disorder found among mainland Puerto Ricans. Guarnaccia 
et al. (1990) posit that recent analyses of the same data set of the 
HANES have revealed consistent differences in the way Hispanics 
conceptualize depression, thus raising questions about the validity 
of traditional assessment of the symptoms of depression in cross- 
cultural studies. Thus, Guarnaccia et al. (1990) question the valid- 
ity of the nosological system in which the instruments (whether DIS 
or CES-D) are based. Although this is a valid assumption, it does 
not explain why mainland Puerto Ricans have almost double the rate 
of island Puerto Ricans in both depressive symptoms and major 



Psychiatric Conditions among Puerto Ricans 11 



depressive episode. It would seem unlikely that mainland Puerto Ri- 
cans hold a significantly different conceptualization of depression 
than island Puerto Ricans. A more plausible explanation given by 
Guarnaccia et al. (1990) is related to the social stress hypothesis. 
Mainland Puerto Ricans exhibit higher rates of unemployment, low 
income, and marital disruption than either Mexican Americans or 
Cuban Americans in the United States. 

Consistent with this social stress hypothesis posited by Guarnaccia 
et al. (1990) is the possibility that mainland Puerto Ricans exhibit 
higher rates of depression or psychiatric symptoms because of selec- 
tive migration. Island Puerto Ricans of marginal mental health, or 
at higher risk because of their low socioeconomic status, may be 
more likely to migrate to New York. This coupled with the aliena- 
tion, prejudice and migration stress which many Puerto Ricans ex- 
perience in the U.S. may render them more vulnerable to psychiatric 
disorder and symptoms. Recent evidence provided by Vera et al. 
(1991) supports the hypothesis of a selective immigration particu- 
larly regarding the migration of low socioeconomic status Puerto Ri- 
cans to the U.S. In this population study, low-income island Puerto 
Ricans were compared to the New York Hanes Puerto Ricans with 
respect to depressive symptoms as measured by the CES-D. Results 
showed that low-income, island Puerto Ricans had similar rates of 
depressive symptomatology compared to New York Puerto Ricans. 
Gender, low educational level, low household income and unemploy- 
ment were found to be predictors of high depressive symptoms for 
both samples. Thus, these results are consistent with the hypothe- 
sis that high levels of at least depressive symptoms among Puerto 
Ricans are mostly explained by socioeconomic status. 

Conclusions of Epidemiologic Studies 

The review of the most recent epidemiologic studies, in which rates 
of either psychiatric symptoms or disorders among island Puerto 
Ricans were compared to other ethnic groups, indicate that no sig- 
nificant differences among ethnic groups were observed when demo- 
graphic differences among the groups were statistically controlled 
and the psychodiagnostic instruments were tested in the culture of 
origin. Salient among the findings was the fact that island Puerto 
Ricans reported high prevalence rates of somatic disorders and symp- 
toms and lower rates of depressive disorders and symptoms, even 
after controlling for socio-demographic correlates. 

Findings from other Latin-American cultures confirm those 



78 Latino Mental Health 



obtained in Puerto Rico, since patients from Colombia and Peru 
(Mezzich and Raab, 1983; Escobar et al., 1983), as well as Hispanics 
in United States communities (Dohrenwend & Dohrenwend, 1969), 
have shown a tendency to present high levels of unexplained physi- 
cal complaints. Several explanations have been given for these higher 
rates of somatic symptoms found among Hispanics. Kirmayer (1988) 
has stated that Hispanics have a different way of comprehending ill- 
ness which eliminates the mind/body dualism inherent in other cul- 
tures. Koss (1990) argues that among Hispanics the psychological 
and physical is one state, intertwined in experience (with neither 
dominating) and that bodily complaints act both as symbols and as 
signposts pointing to social and interpersonal distress. Others 
(Kolody et al., 1986) have stated that somatic symptoms among 
Hispanics may be masking depressive symptomatology. Yet the find- 
ings of Rubio-Stipec et al. (1990) do not seem to support this 
hypothesis. In that study, factor analyses of the DIS symptoms re- 
vealed a somatization factor, which was distinct and independent 
from the depression factor. 

While somatic symptoms are more prevalent among island Puerto 
Ricans, depressive symptoms and disorders are less prevalent as com- 
pared to either mainland Puerto Ricans or other ethnic groups in- 
cluding Anglo-Americans. It is possible that this lower prevalence 
of depression among island Puerto Ricans may be related to the high 
levels of social, community and family support reported by the popu- 
lation (Bravo et al., 1991b). Social and family support have been 
found to serve as buffers against depression (Brown & Harris, 1986). 
The breaking of support networks with migration might be one of 
the factors placing mainland Puerto Ricans at greater risk of depres- 
sive symptoms. 

In conclusion, we may state that possibly a combination of fac- 
tors explain the higher prevalence of mental health problems ex- 
hibited among mainland Puerto Ricans. A selective migration 
process placing immigrants of lower socioeconomic status at greater 
risk for psychiatric disorder; the disruption of social and family sys- 
tems; the alienation and prejudice experienced by this group in the 
U.S.; and finally the stress of the migratory process, per se, are all 
factors which possibly contribute to a higher rate of mental disorder 
or symptoms among this population. 

We can therefore conclude that there is no hard evidence in favor 
of the contention that either mainland or island Puerto Ricans are 
at higher risk of psychiatric disorders or symptoms because of any 



Psychiatric Conditions among Puerto Ricans 79 



inherent aspect of their culture. Yet this does not mean that culture 
does not influence the manifestation or occurrence of psychiatric dis- 
orders. Several limitations of the above mentioned epidemiologic 
studies do not make them the best source for the study of culture 
specific syndromes. In particular, the cultural sensitivity of the psy- 
chodiagnostic instruments used and the lack of concurrent ethno- 
graphic research constitute significant limitations. 

Are Diagnostic Instruments Used in 
Epidemiologic Research Culture Sensitive? 

The fact that very few differences were identified regarding the 
prevalence rates of psychiatric disorders or the mean number of sym- 
ptoms associated with these disorders, in the comparison of island 
Puerto Ricans with other ethnic groups, does not mean that the is- 
sue of cross-cultural differences in psychopathology has been set- 
tled. The fact that the reliability and validity of an instrument like 
the DIS have been tested in the host culture (Canino et al., 1987b; 
Bravo et al., 1991a) does not necessarily assure complete cultural sen- 
sitivity of the instrument. The validity of DSM III diagnostic 
categories has not been assessed in Hispanic populations, and the 
DIS is based in this nosology. It is possible that in using DSM-III, 
which was developed for use among Euro-Americans in the United 
States, we are imposing an artificial cultural homogeneity in the 
prevalence of mental disorders and symptomatology. Kleinman and 
Good (1985) have stated that one of the consequences of the 
"category fallacy" is the appearance of cross-cultural homogeneity 
which is artifactual to the use of a constricted nosology. 

But how can a category fallacy in cross-cultural research be 
avoided? The answer is not simple if it is considered that, for the 
most part, the validity of the majority of diagnostic categories has 
not been established even for the culture for which the nosology was 
developed. Researchers and clinicians are still struggling with defin- 
ing a "gold standard," or the best criterion to use as an external 
validator for establishing the validity of psychiatric diagnoses 
(Robins, 1985). 

The fact that this is the state of the art in mainstream psychiatry 
does not mean that there is nothing to be done in cross-cultural 
research to diminish cultural bias or to increase the cultural sensi- 
tivity of the instruments used. The use of a culturally sensitive trans- 
lation and an adaptation process which involves ethnographic 
methods; the inclusion of indigenous categories of experience; the 



80 Latino Mental Health 



testing of the psychometric properties of the instrument in the host 
society; and the inclusion of indigenous researchers in the investiga- 
tive team, are methods used in culturally sensitive research which can 
diminish cultural bias (Rogler, 1989). 

Translation and Adaptation of Instruments 

Kleinman (1987) has stated that translation is the very essence of 
ethnographic research. Multiple linguistic and sociocultural factors 
must be considered. To a certain extent the epidemiologic studies of 
island Puerto Ricans used a translation and adaptation model based 
on various methods (Flaherty, 1987; Brislin et al., 1973; Gaviria et 
al., 1984), which evaluate the cultural equivalency of the research 
instruments in five dimensions: semantic, content, technical, 
criterion and conceptual. This process has been described in detail 
elsewhere (Bravo et al., 1987; Canino et al., 1987b). Nonetheless, 
problems were encountered in certain concepts that were difficult 
to translate; for example, idiomatic expressions or particular ways 
a culture has of expressing internalized emotions such as "feeling 
blue or down", "feeling high", etc. Other difficulties which emerged 
included measuring with reliability some of the DSM III time related 
criteria; re-phrasing complex questions which were difficult to un- 
derstand for low socioeconomic status subjects; and measuring psy- 
chotic symptomatology, like delusions and hallucinations, which are 
more common among persons of certain religious beliefs and among 
practitioners of spiritualism and santeria (Guarnaccia et al., 1992). 

Although the results of the testing of the psychometric properties 
of the Spanish DIS used in Puerto Rico (test-retest reliability and 
concordance with clinical diagnosis) (Canino et al., 1987b) were simi- 
lar to those obtained in the U.S. (Robins et al., 1982), poorer con- 
cordance between DIS internalizing disorders, such as obsessive 
compulsive disorder, schizophrenia and dysthmia, and the clinical 
judgement of indigenous psychiatrists was salient in the island. An 
attempt was made to resolve this difficulty by analyzing prevalence 
rates with and without modification to the algorithms of the DIS for 
dysthymia and obsessive compulsive disorder so that they could 
reflect the Puerto Rican cultural context (Canino et al., 1987a). In 
addition, the clinical editing of the schizophrenia section of the DIS 
(Guarnaccia et al., 1992) and the ethnographic analysis of the 
verbatim descriptions of symptoms and events of island respondents 
were carried out. 



Psychiatric Conditions among Puerto Ricans 



Ethnographic Analysis 

One limitation of the majority of epidemiologic studies quoted has 
been the lack of adequate ethnographic information prior to the field 
work, which could permit the measurement of possible "culture 
specific syndromes" or particular ways populations may have of ex- 
pressing certain psychiatric symptomatology. Ethnographic tech- 
niques were used by Guarnaccia et al. (1989) to analyze verbatim 
expressions of some DIS items in the Puerto Rico epidemiologic sur- 
vey. As a result of these analyses, it was found that a number of per- 
sons who reported having a panic attack in their verbatim response 
to question 62 of the DIS, often expressed experiencing an "ataque 
de nervious". This has been described by investigators (Guarnaccia 
et al., 1989; De La Cancela et al., 1986) as a dramatic episode in 
which persons of Hispanic origin tremble; feel heart palpitations and 
other somatic symptomatology; begin to shout; sometimes become 
aggressive; and then fall on the floor unconscious. An "ataque de 
nervios" scale was developed with the somatization items of the DIS 
which resemble the cluster of symptoms typical of the syndrome 
(Guarnaccia et al., 1989). The reliability of the scale was tested and 
the number of people in Puerto Rico who scored high in the scale 
was estimated and their demographic and diagnostic characteristics 
were also described. 

In a second epidemiologic survey of the island performed in 1987 
by Canino and colleagues, prompted by Dr. Peter Guarnaccia, an 
item was added to the DIS which asked the respondent whether they 
had ever experienced an "ataque de nervios" and a verbatim descrip- 
tion of the symptomatology and precipitating factors was obtained. 
Analyses of the data revealed that 12% of the population reported 
having experienced a "nerve attack" once in their lifetime and that 
more than half of these also met criteria for either a depressive or 
anxiety disorder (Guarnaccia, 1991). The Puerto Rico team is now 
in the process of analyzing in more detail these results with Dr. Peter 
Guarnaccia, in order to determine with empirical epidemiologic evi- 
dence, whether "ataques de nervios" are a true culture-bound psy- 
chiatric syndrome, or are merely a cultural idiom of common people 
for describing some cultural manifestations of episodic psychiatric 
conditions, such as anxiety or depression. Future research in this area 
will involve revisiting this 12% of the population who reported a 
"nerve attack" and performing a complete ethnographic descrip- 
tion of the "attack"; the development of a scale to more adequately 



82 Latino Mental Health 



measure these symptoms or syndrome; and a complete clinical evalu- 
ation of this sub-sample by indigenous psychiatrists to determine the 
presence or absence of specific psychiatric diagnose. 

Suggested Direction For Future Hispanic Research 

Methodological and Ethnographic Research. 

Combining ethnographic and empirical epidemiological ap- 
proaches is essential, in order to better define what constitutes a case, 
particularly when using a psychiatric nosology which was developed 
for another culture. Ethnographic research can also offer plausible 
explanations for some surprising findings. For example, in both the 
1985 children's survey of Puerto Rico (Bird et al., 1988), and in 
the 1987 adult survey (Canino et al., 1993), the prevalence of drug 
addiction in the children, adolescent and adult populations was 
found to be less than 2%. Furthermore, the prevalence of conduct 
disorder in children and of antisocial personality in adults was less 
than one percent of these respective populations. These very low 
prevalence rates of drug addiction, antisocial personality and con- 
duct disorder in the Puerto Rican population run counter to the fact 
that the island has one of the highest crime rates in the nation and 
one of the highest incidence rates of drug related AIDS in the world. 
Ethnographic research which would investigate the response styles 
of this population with respect to inquiries concerning illegal be- 
havior would be useful for the interpretation of these results. Fur- 
thermore, methodological studies in which different methods of 
ascertainment are used for assessing stigmatizing behaviors would 
be necessary. 

Cross Cultural Comparisons. 

One way of reducing ethnocentrism and of disentangling substan- 
tive from methodological issues is by comparing epidemiological 
results across different cultures in which similar instruments and 
methods were used. We have seen how in the field of adult psy- 
chiatric epidemiology these comparisons have been useful (Helzer 
et al., 1990). The field of child psychiatric epidemiology has also be- 
gun to make cross-cultural comparisons with the similar finding that 
the prevalence of most DSM III psychiatric disorders does not vary 
across cultures. We need to do more of these comparisons, particu- 
larly with South American countries and Spain which share with 
U.S. and island Puerto Ricans and other U.S. Hispanics a common 
heritage. The merging of population data sets of island Puerto Ri- 



Psychiatric Conditions among Puerto Ricans 83 



cans, mainland Hispanics, South Americans, and other ethnic 
groups from other countries, which have been assessed by the same 
diagnostic instruments, would be essential. This would permit us to 
begin to disentangle the extent to which societal context and culture 
influences the prevalence and correlates of mental disorders and the 
extent to which genetics may play a role. The inclusion of ethno- 
graphic work prior to the epidemiological field survey would be of 
great value, in order to ascertain whether prior commonalities found 
in cross-cultural epidemiological research are the results of a 
"category fallacy". 



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6 



Factors Associated with 

Psychological Distress Among 

Mexican-American and Anglo Populations 

Residing in a Border City 

David F. Briones, M.D., Peter L. Heller, Ph.D. 

Salvador F. Aguirre-Hauchbaum, M.D. 

H. Paul Chalfant, Ph.D., Alden E. Roberts, Ph.D., 

Walter F. Farr, Jr., M.D. 



Existing literature concerning Mexican-American psychological 
distress can be subsumed under either the minority status or ethnic 
culture perspective (Mirowsky & Ross, 1980). The former view con- 
tends that so-called ethnic variations in incidence of psychological 
distress (e.g., Anglo vs. Mexican-American) is an artifact of the ten- 
dency for minority persons to disproportionally hold membership 
in the under class. In this view, socioeconomic status (SES), rather 
than ethnicity, is the important determinant of psychological distress. 
According to the ethnic culture perspective, psychological distress 
is one manifestation of a particular type of ethnic culture. Represen- 
tative of this view is Mirowsky and Ross's (Mirowsky & Ross, 1984) 
assertion that fatalism, as a Mexican cultural trait carried over in 
Mexican- American populations, leads to a relatively high incidence 
of depression. According to these authors, another Mexican cul- 
tural trait, strong familial and friendship support, tends to protect 
Mexican- Americans against anxiety. Elsewhere (Heller, et al., 1990) 
in a more theoretical paper, we have developed and tested an ana- 
lytic path model that attempts to place the minority status versus eth- 
nic culture debate concerning psychological distress in broader 
perspective. 

In this work we report findings from a more straight forward mul- 
tiple regression analysis that assesses comparative strengths of the 
variables, Anglo versus Mexican- American ethnicity and SES, as 
predictors of depression and anxiety. After this assessment, ethnicity 



88 Latino Mental Health 



and SES are entered into multiple regression equations along with 
a number of mediating and control variables gleaned from relevant 
literature. Through this type of analysis, it is possible to ascertain 
the strength of each variable as a predictor of psychological distress 
after controlling for effects of all other variables in a theoretical 
framework. Each variable is discussed, along with a brief summary 
of research findings related to its possible effects on psychological 
distress. 

Ethnicity and Socioeconomic Status 

Existing research literature is unclear regarding the relative inci- 
dence of psychological distress among Anglo and Mexican Ameri- 
can populations. A majority of studies have concluded that the 
psychological distress is not a major Mexican American problem. 
These studies ( Antunes et al., 1974; Burnam et al., 1984; Mirowsky 
& Ross, 1980, 1984; Quesada et al., 1978; Ross et al., 1983a; Ross 
et al., 1983b) show either a lower incidence of psychological distress 
among Mexican Americans, in comparison with Anglos, or no sig- 
nificant differences in distress symptoms. Related findings from Bur- 
nam et al. (1987) show that Mexican immigrants to the United States 
possess relatively low levels of psychological distress. 

Opposite findings have been presented (Burnam et al., 1983) where 
Anglos were found to report fewer distress symptoms. Others also 
have found rates of psychological distress among Mexican Ameri- 
cans equal to or higher than those reported for Anglos (Roberts, 
1980; Roberts, 1981; Roberts & Vernon, 1984). These authors be- 
lieve that many of the studies finding a low incidence of psycholo- 
gical distress among Mexican-Americans are biased, in terms of 
scoring procedures used in tabulating distress scales. According to 
Roberts and Vernon (1984), alleged ethnic differences in psycholo- 
gical distress are largely a function of social class. 

Studies concerning the relationship between SES and psycholog- 
ical distress have almost invariably found an inverse relationship be- 
tween SES and a tendency towards psychological distress (Boyd & 
Weissman, 1982; Dohrenwend & Dohrenwend, 1974; Eaton, 1980; 
Hirschfield & Cross, 1982; Roberts, 1984; Roberts et al., 1982). If 
SES constitutes the decisive factor in psychological distress, one 
would think that under-class Mexican-Americans would possess a 
high degree of this attribute. In addition to poverty, Mexican- 
Americans are subjected to prejudice, discrimination and linguistic 
barriers (Cockerham, 1989). Thus, the above-cited cultural argument 



Factors Associated with Psychological Distress 89 



by Mirowsky and Ross (1984) would be rejected by researchers sub- 
scribing to the minority status perspective. 

Mediating Variables 

Fatalism, the opposite of perceived environmental mastery, is fre- 
quently seen as a contributing factor to psychological distress. 
Mastery is defined as a feeling of personal competence of ". . . ef- 
fectiveness in dealing with and overcoming the problems of life" 
(Mirowsky & Ross, 1984, p. 2.). Mastery is considered to be one 
prerequisite of good mental health, because a fatalistic orientation 
breeds passivity in the face of environmental problems (Dohrenwend 
& Dohrenwend, 1970). According to Mirowsky and Ross (1989), a 
lack of mastery (powerlessness in their terminology) can affect psy- 
chological distress directly or indirectly. Passivity towards negative 
life events directly leads to increased distress because this orienta- 
tion impedes coping. Indirectly, fatalism can influence distress by 
inhibiting one's will to make a decision or to seek out potential 
sources of help. 

Another variable that has been widely linked to psychological dis- 
tress is social support and/or institutional support. Possession of a 
support network is either said to directly reduce one's probability 
of having to endure psychological distress (Brim et al., 1982; Cohen 
& Wills, 1985; Pittman, 1988; Procodano & Heller, 1983; Williams 
et al., 1981), or to serve as a buffer (Antonovsky, 1974; Cohen, 1985; 
Husaini et al., 1982; Kaplan et al., 1983; LaRocco, 1980; Myers et 
al., 1975; Pearlin et al., 1981; Wheaton, 1985) for those undergo- 
ing a series of negative life events. It has been suggested, however, 
that intense networks of familial and peer support may or may not 
decrease psychological distress. Mettlin and Woelfel (1974) note that 
interpersonal influence can be stressful in itself because of the volume 
of influence originating from several sources. Corse, Schmid and 
Trickett (1990) support this view with findings that abusive mothers 
tend to have troubled relationships with relatives. Further, Cohen 
and McKay (1984) suggest that specific support domains must be 
related to specific effects. Emphasized in our research is the concept 
of meaningful network of support. By "meaningful" network we 
refer to institutional, familial and friendship involvements that can 
be relied upon during actual occurrence of a stressful life event. 
Meaningful support involves a broad non-intense network of friends, 
relatives, and/or institutions that can be called upon for the satis- 
faction of specific needs. 



90 Latino Mental Health 



Life-stress 

Life-stress constitutes another widely cited contributor to psy- 
chological distress. The role of life stress as a determinant of psy- 
chological distress has been studied extensively (Cockerham, 1989; 
Pearlin et al., 1981; Ross & Mirowsky, 1979; Thoits, 1981). General 
agreement exists that an accumulation of stressful life events tends 
to adversely affect mental health. Although effects of life stress on 
psychological distress are usually considered in relation to support 
(Cockerman, 1989; Mirowsky & Ross, 1989), life stress is addressed 
in this research as a possible mediating variable in the relationship 
between ethnicity, and/or SES, and psychological distress. 

Although not found in existing literature, lack of money to pur- 
chase necessities (or financial hardship) is certainly a determinant 
of psychological distress. Inability to afford such necessities as ac- 
ceptable housing, an automobile, food, clothing, and medical care 
places a considerable psychological strain on an individual. For this 
reason, financial hardship is included as a potential mediating vari- 
able in this study. 

Finally, the variables age and gender have been found to influence 
psychological distress. Age and gender are included in this study as 
control variables. Women tend to possess higher rates of psycholo- 
gical distress than men (Clancy & Gove, 1974; Kessler et al., 1981; 
Weissman, 1979). Elderly persons tend to possess relatively high rates 
of depression, but age has not been found to correlate with anxiety 
(Mirowsky & Ross, 1989). 

To summarize, the focus of this research is on the relative abi- 
lity of the minority status and ethnic culture perspectives to explain 
the incidence of generalized depression and anxiety in Anglo- and 
Mexican- American populations residing in a United States border 
city. Results from step-wise multiple regression analyses will be 
presented and discussed. Initially, relative effects of ethnicity and 
SES on depression and anxiety will be examined. This examination 
will be followed by an assessment of the potency of ethnicity and SES 
as explanatory variables after potential mediating and control vari- 
ables are entered into analyses. Results will then be assessed in terms 
of their clinical implications for mental health practitioners. 

Methods 

A stratified random sample of 806 respondents residing in El 
Paso, Texas was selected and interviewed during 1985-1986. The 



Factors Associated with Psychological Distress 91 



sampling procedure consisted of selecting census tracts varying in 
median income and ethnic composition. A scarcity of upper-middle- 
class Hispanic and under-class Anglo census tracts necessitated some 
deviation from randomness. A combination of random and quota 
sampling was devised for these numerically under-represented group- 
ings. Respondents refusing to be interviewed and "not-at-homes" 
(after three call-backs) comprised eight and 12 percent respectively 
of the original sample. These households were replaced by others 
within the same city block by means of a random replacement proce- 
dure. In accordance with conventional selection goals of population 
researchers (Kish, 1965; Babbie, 1973), five households per randomly 
selected block were interviewed. Every attempt was made to insure 
representative samples of Mexican- and Anglo-American respon- 
dents. In all, on the basis of self classification, life history questions, 
and interviewers' independent assessments, 783 of the 806 respon- 
dents could be unambiguously classified as Mexican or Mexican- 
American (n = 446) or Anglo-American (n = 337). The 23 unclas- 
sifiable respondents have been excluded from statistical analyses. 
Data were collected by means of structured face-to-face interviews. 
The interview schedule was originally written in English and subse- 
quently translated into Spanish by means of a cross-translation 
procedure. Interviews were conducted in Spanish or English accord- 
ing to respondent's preference. 



Variable Measures 

The two psychological distress variables (depression and anxiety) 
were measured by published scales that have been well-received by 
survey researchers in the area of mental health. Psychological depres- 
sion (depressive symptomatology) was measured by the CES-D scale, 
a 22-item scale developed by the Center of Epidemiological Studies, 
National Institute of Mental Health. The scale has been well tested 
(Radloff, 1977) and extensively used (Roberts, 1981). These 22 
depression items formed a highly reliable scale among the El Paso 
sample, achieving a Cronbach's alpha of 0.924. Anxiety was meas- 
ured by a factor analyzed symptom index developed by Ilfeld (1979). 
Cronbach's alpha for this scale among the El Paso sample was 0.821 . 
Respondents were asked how frequently they had experienced 
11 anxiety-related symptoms during a seven-day period prior to 
interview. 

Two independent, four mediating and two control variables 
appear in multiple regression analyses reported in Table 2 and 



92 Latino Mental Health 



Table 3. The study's two major independent variables are ethnicity 
and SES. 

Ethnicity and Socioeconomic Status 

A number of authors (Mirowsky & Ross, 1984; Olmedo, 1978; 
Yancy, 1979) suggest that Mexican- American ethnicity is a continu- 
ous rather than discrete variable. In agreement with this position, 
"Mexican" ethnicity has been defined as a person's degree of in- 
volvement in "Mexican things". A Mexican acculturation scale was 
constructed from factor-analyzed items developed by Cuellar, Harris 
and Jasso (1980). Ten scale items measure degree to which certain 
activities and events are important, such as Mexican songs, fiestas, 
culture, and sports. Scale scores can range from zero (Anglos and 
Mexicans/Mexican- Americans who are culturally Anglo) to 40 (Mex- 
icans/Mexican-Americans who are strongly immersed in Mexican 
culture). Scale items (multiplied by their factor loadings) are 
summed. Cronbach's alpha for this scale is 0.962. Degree of formal 
education and yearly family income have been combined to form a 
SES scale. Z-scores were computed for education and income prior 
to combining the two variables. 

Mediating and Control Variables 

The mediating and control variables are life stress, financial hard- 
ship, perceived environmental mastery and possession of meaningful 
support comprise the study's mediating variables. Life stress is meas- 
ured by 23 questions related to non-health and health-related stress- 
ful life events taken from Thoits (1981). Respondents were asked if 
any of these events had occurred within a period of approximately 
one year prior to interview. Events are summed to give respondent's 
life-stress score (Thoits, 1981). Financial hardship is measured with 
questions concerning nine economic strains typically experienced by 
adult individuals (Pearlin, 1981). These questions deal with difficulty 
reported in being able to afford such things as housing, household 
equipment, an automobile, food, medical care, clothing, and leisure 
activities; the ability to pay one's bills; and respondent's general as- 
sessment of his or her financial situation. 

Perceived environmental mastery is measured by a seven-item scale 
developed by Pearlin et al. (1981). These items measure the extent 
to which respondents see themselves as being able to control forces 
affecting their daily lives. Responses to these items range from 
"strongly agree" to "strongly disagree", with no "undecided" 
category included in the response format. Response codes run from 



Factors Associated with Psychological Distress 93 



1 through 4, with "4" representing the highest promastery response 
to a particular statement. Cronbach's alpha for the mastery scale is 
0.780. Originally social and institutional support were to be included 
in the model as separate variables. The two measures, however, cor- 
related sufficiently to present problems of colinearity during mul- 
tiple regression analyses. Thus, the two scales were combined into 
one general meaningful support scale after z-scores were computed 
for each. Respondents were read five statements dealing with loss 
of income and hospitalization of spouse over a several week period. 
Statements dealt with the extent to which respondent would possess 
familial, friendship and/or institutional support during such stressful 
periods. Responses to these statements were numerically coded as 
(1) "This statement in no way fits my life today;" (2) "This state- 
ment somewhat fits my life today;" and (3) "This statement strongly 
fits my life today." Responses from these five statements have been 
summed to form a general support score for each respondent. 
Respondent's age and sex are included in multiple regression ana- 
lyses as control variables. Age is coded as given. Sex is coded in 
dummy form (female = 1; male = 0). 

Data Analysis 

Data are analyzed through a step-wise multiple regression ana- 
lysis for depression and anxiety. Scales and other variable measures 
are brought into the step-wise analysis in three blocks. In the first 
block, ethnicity and SES are regressed on psychological distress 
(depression in Table 2, anxiety in Table 3). Added to these in the 
second block are life stress and degree of financial hardship. In the 
third block, all eight of the independent, mediating and control vari- 
ables are regressed on psychological distress. This procedure allows 
an initial comparison of the relative predictive power of ethnicity and 
SES on psychological distress before and after combined effects of 
mediating and control variables are added to the equation. 

Results 

Correlation coefficients, means and standard deviations are pre- 
sented in Table 1 . Summarized in Table 2 and Table 3 are results 
from stepwise multiple regression analyses concerning depression 
and anxiety. These latter tables include unstandardized and stan- 
dardized regression coefficients (after controlling for effects of other 
variable(s) entered within the same block) and the square of the mul- 
tiple correlation coefficient (R 2 ) for all variables included in a given 
block. Discussion of results summarized in these tables will focus on 



94 Latino Mental Health 



ethnicity and SES as potential determinants of depression and/or 
anxiety. 

Results shown in Table 1 indicate that, at the bivariate level, de- 
pression and anxiety correlate more highly with SES than with eth- 
nicity. Correlation coefficients between SES, depression and anxiety 
are - 0.346 and - 0.219 respectively. Corresponding coefficients for 
ethnicity are 0.231 and 0.130. Correlation coefficients in Table 1 also 
show that, with the exception of life stress, each of the mediating 
variables correlates more highly with SES than with degree of 
Mexican acculturation. Higher status persons tend to possess a rela- 
tively low degree of economic hardship, a relatively high degree of 
meaningful social and institutional support, and a perception of 
mastery over their environments. Degree of Mexican acculturation, 
however, also correlates in a meaningful way with economic hard- 
ship, possession of meaningful support, and perception of mastery. 
Nevertheless, SES appears to be the more important determinant of 
these variables. As an aside, it is interesting to note that number of 

Table 1. Correlations, Means, and Standard Deviations (N = 783) 





1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


1. Sex 
(female) 


1.00 




















2. Age 


-0.08 


1.00 


















3. Ethnicity a 


0.04- 


-0.10 


1.00 
















4. SES b 


-0.04- 


-0.15- 


-0.51 


1.00 














5. Life Stress 


-0.02 


0.02- 


-0.03- 


-0.02 


1.00 












6. Economic 
Hardship 


0.06 


-0.06 


0.37- 


-0.60 


0.13 


1.00 










7. Support 


0.09 


-0.12- 


-0.40 


0.62- 


-0.01 


0.65 


1.00 








8. Mastery 


0.07- 


-0.17- 


-0.32 


0.51- 


-0.20- 


-0.43 


0.44 


1.00 






9. Depression 


0.14- 


-0.02 


0.23- 


-0.34 


0.32 


0.40- 


-0.31- 


-0.50 


1.00 




10. Anxiety 


0.12- 


-0.05 


0.13- 


-0.22 


0.37 


0.25- 


-0.20- 


-0.38 


0.73 


1.00 


Mean 


0.60 


47.02 


17.42 - 


-0.00 


2,09 


1.71 


0.00 


15.03 


28.34 


14.09 


Standard 
Deviation 


0.49 


17.26 


7.83 


1.79 


1.99 


2.32 


1.77 


3.00 


10.22 


4.70 



a Degree of Mexican acculturation 

b Education and income variables were transformed into standardized (z) scores 



Factors Associated with Psychological Distress 95 



life stress events during a 12-month period does not significantly 
correlate with either SES or degree of Mexican acculturation. Ap- 
parently, members of all SES categories, whether Anglo or Hispanic, 
are almost equal in likelihood of being subjected to life stress. Of 
course, ability to adapt to these stressors has a great deal to do with 
such factors as ethnicity, SES, possession of support, and perceived 
environmental mastery. 

Multiple Regression Analyses 

Due to similarity of findings summarized in Tables 2 and 3, the 
results of the Multiple Regression Analysis for depression and anxi- 
ety will be directly compared. As previously noted, variables were 
entered into multiple regression analyses in three blocks. In the first 
block (sub-Table 2a and sub-Table 3a), ethnicity and SES are 
regressed against depression or anxiety, in order to ascertain the 
predictive strength of each of these independent variables after con- 
trolling for effects of the other. Standardized regression coefficients 
(betas) in sub-Table 2a and sub-Table 3a show that both ethnicity 
and SES are significantly associated with depression and anxiety, af- 
ter controlling for effects of the other variable. In agreement with 
findings reported in Table 2, however, SES is by far the stronger 
predictor of psychological distress. Betas for SES on depression and 
anxiety, after controlling for ethnicity, are -0.300 and -0.193, 
respectively. Corresponding betas for ethnicity are 0.081 and 0.035. 

A similar pattern exists in sub-Tables "b" of Table 2 and Table 
3. Entered with ethnicity and SES are life stress and degree of finan- 
cial hardship. For depression (sub-Table 2b), ethnicity remains sig- 
nificant even after effects of SES, life stress and financial hardship 
are removed from the equation. The beta for SES also remains 
statistically significant, after controlling for effects of ethnicity, life 
stress and financial hardship. SES, however, remains the stronger 
predictor of depression. Concerning anxiety (sub-Table 3b), the ef- 
fects of ethnicity become non-significant, after controlling the ef- 
fects of SES, life stress, and financial hardship. Effects of SES on 
anxiety, however, do remain statistically significant. Again, the pat- 
tern of these findings suggests that, of ethnicity and SES, the latter 
variable is the more important determinant of psychological distress. 

Findings in sub-Tables "b" of Table 2 and Table 3 hint at an un- 
expected finding that becomes clearer in sub-Tables "c". Note that 
the mediating variables life stress and financial hardship (sub-Table 
2a) are stronger predictors of depression than either ethnicity or SES. 



96 Latino Mental Health 



Table 2a-c. Unstandardized and (Standardized) Regression Coefficients 
for Predicting Depression 2 



2a. Effects of Ethnicity, and Socioeconomic Status 


Independent Variable 


Dependent Variable: 
Depression 


Ethnicity b 
Degree of Mexican acculturation 


0.110 


( 0.081)* 


Socioeconomic status 
R 2 = 0.12 


-1.748 


(-0.300)*** 


2b. Entering Life Stress and Financial Hardship 


Degree of Mexican acculturation 


0.089 


( 0.068)* 


Socioeconomic status 


-0.893 


(-0.153)*** 


Number of life-stress events during past 12 months 


1.493 


( 0.291)*** 


Lack of money to buy necessities 
R 2 = 0.26 


1.102 


( 0.249)*** 


2c. Entering Mastery, Social and Institutional Support, Age and Sex 


Degree of Mexican acculturation 


0.021 


( 0.016) 


Socioeconomic status 


-0.281 


(-0.048) 


Number of life-stress events during past 12 months 


1.203 


( 0.234)*** 


Lack of money to buy necessities 


0.706 


( 0.160)*** 


Mastery 


-0.213 


(-0.357)*** 


Support 


-0.116 


(-0.027) 


Age 


-0.044 


(-0.075)* 


Sex (female) 

R 2 = 0.36 


2.098 


( 0.110)*** 



a Cronbach's alpha for depression scale is 0.924 

b Cronbach's alpha for Mexican acculturation scale is 0.962 

c Cronbach's alpha for mastery scale is 0.780 

*p 0.05 

**p0.01 

***p 0.001 

The same is true of life stress in sub-Table 3b, where the beta (0.355) 
for this variable regressed against anxiety is much stronger than that 
(-0.115) for SES. Unlike findings for depression, however, SES and 
financial hardship (beta = 0. 118) are relatively equal predictors of 
anxiety. 

In sub-Tables "c" of Table 2 and Table 3, respectively, the re- 
maining mediating and control variables are entered into the mul- 



Factors Associated with Psychological Distress 97 



tiple regression equation. With the inclusion of these variables, 
neither ethnicity nor SES is significantly associated with psycholo- 
gical distress. We suspect that part of this finding is an artifact of 
colinearity between SES and financial hardship. The correlation 
coefficient between these two variables in Table 1 is -0.601. Thus, 
knowledge of either of these variables explains 36 percent of vari- 
ance in the other. Similar problems of colinearity exist between pos- 
session of meaningful support and SES (r 2 = 0.48), and between 



Table 3a-c. Unstandardized and Standardized Regression Coefficients 
for Predicting Anxiety 3 



3a. Effects of Ethnicity and Socioeconomic Status 


Dependent Variable: 
Independent Variable Anxiety 


Ethnicity 
Degree of Mexican acculturation 0.021 


( 0.035)* 


Socioeconomic Status -0.519 
R 2 = 0.04 


(-0.193)*** 


3b. Entering Life Stress and Financial Hardship 


Degree of Mexican acculturation 0.028 


( 0.039) 


Socioeconomic status -0.308 


(-0.115)** 


Number of life-stress events during past 12 months 0.839 


( 0.355)*** 


Lack of money to buy necessities 0.240 
R 2 = 0.19 


( 0.118)** 


3c. Entering Mastery, Social and Institutional Support, Age and Sex 


Degree of Mexican acculturation 0.008 


( 0.013) 


Socioeconomic status -0.033 


(-0.012) 


Number of life-stress events during past 12 months 0.729 


( 0.308)*** 


Lack of money to buy necessities 0. 132 


( 0.065) 


Mastery - 0.447 


(-0.285)*** 


Support -0.007 


(-0.004) 


Age 0.002 


( 0.007) 


Sex (female) 0.990 
R 2 = 0.26 


( 0.103)** 



a Cronbach's alpha for anxiety scale is 0.876 
*p 0.05 
**p0.01 
***p 0.001 



98 Latino Mental Health 



perceived environmental mastery and SES (r 2 = 0.26). Thus, it is 
far from clear that SES is a non-significant contributor to psycho- 
logical distress. Colinearity problems also exist for ethnicity, but not 
to the same degree as for SES. The correlation coefficient (refer to 
Table 1) between degree of Mexican acculturation and financial 
hardship is 0.372. Thus, 14 percent of the variance in one of these 
variables is explained by the other. In addition, similar conditions 
exist between ethnicity and support (r 2 = 0.21), and ethnicity and 
mastery (r 2 = 0.10). Thus, although findings in Table 1, and sub- 
Tables "c" of Table 2 and Table 3 clearly indicate that SES is a much 
more important indicator of psychological distress than is ethnicity, 
it cannot be clearly stated that neither of these variables is of 
relevance after mediating and control variables are entered into the 
multiple regression equation. 

On the other hand, findings in sub-Table 2c and sub-Table 3c 
clearly indicate the importance of variables other than ethnicity and 
SES in explaining onset of depression and anxiety. After controll- 
ing for all other variables in the equation, perceived environmental 
mastery (beta = 0.357) and life stress (beta = 0.234) are strong de- 
terminants of depression. These two variables exert a powerful in- 
fluence on anxiety as well (betas = 0.285 and 0.308). Thus, 
independently of ethnicity, SES, and other mediating and control 
variables entered into block "c" (Table 2 and Table 3) both a fatalis- 
tic orientation, and subjection to negative life events, respectively, 
are sufficient in themselves to bring on the two forms of psycholog- 
ical distress under consideration. No other variable in block "c" 
comes close to mastery and life stress in explanatory power. It should 
be noted, however, that financial hardship, age and sex are also sig- 
nificantly associated with depression and that sex is significantly as- 
sociated with anxiety. Interestingly, financial hardship appears to 
directly influence depression but not anxiety. Age also directly, but 
inversely, affects depression, but not anxiety. This finding is anoma- 
lous in that the elderly have been found (Mirowsky & Ross, 1989) 
to possess a relatively high incidence of depression. It should be 
noted that the bivariate correlation between age and depression (refer 
to Table 1) was only -0.02, and although statistically significant, 
the beta of -0.075 for age on depression (sub-Table 2c) does not 
indicate a particularly strong degree of association between these 
variables. Nevertheless, findings in sub-Table 2c do indicate, that, 
among El Paso respondents, age is inversely associated with posses- 
sion of depressive symptomatology. Unlike age, the gender varia- 



Factors Associated with Psychological Distress 99 



ble does associate with psychological distress as predicted in literature 
cited above. The sex of the respondent significantly and indepen- 
dently associates with depression and anxiety. Females are more 
likely then their male counterparts to possess psychological distress. 
Finally, the square of the multiple correlation (r 2 ) coefficient in- 
dicates the combined strength of variables entered together within 
a particular block in predicting depression or anxiety. The r 2 in sub- 
Table 2a indicates that 12 percent of the variance in depression is ex- 
plained through the combined effects of ethnicity and SES. Thus, 
in combination, ethnicity and SES do meaningfully contribute to our 
understanding of depression. SES, however, constitutes the major 
contributing factor in explaining depression. Concerning anxiety 
(sub-Table 3a) the combined explanatory power of ethnicity and SES 
is relatively weak. The r 2 in this sub-table indicates that only four 
percent of the variance in anxiety is explained by these variables. 
When life stress and financial hardship are entered into the multi- 
ple regression equation with ethnicity and SES (sub-Table 2b and 
sub-Table 3b), the percentages of explained variance in depression 
and anxiety increase to 26 and 19. Thus, life stress and financial 
hardship increase the percentage of explained variance in depression 
by 14 percent and in anxiety by 15 percent. When all variables un- 
der consideration are entered into the multiple regression equation 
(sub-Table 2c and sub-Table 3c), their combined effects explain 36 
percent of the variance in depression and 26 percent of the variance 
in anxiety. Inclusion of life stress, financial hardship, mastery, sup- 
port, age and sex increased the explained variance in depression, over 
SES and ethnicity alone, by 24 percent; and anxiety by 22 percent. 
Thus, in combination, variables under consideration in this study 
do indeed contribute to our understanding of psychological distress 
among residents of El Paso. 

Clinical Implications 

Findings in this study tend to support the minority status perspec- 
tive concerning psychosocial determinants of anxiety and depression. 
Correlation coefficients (refer to Table 1) and standardized regres- 
sion coefficients (refer to Table 2 and Table 3) point to SES, over 
ethnicity, as the stronger determinant of depression and anxiety. 
Nevertheless, ethnicity (defined as degree of Mexican acculturation) 
is significantly associated with depression and anxiety even after 
controlling for effects of SES. Thus, both of these variables are 
meaningful contributors to psychological distress. 



1 00 Latino Mental Health 



Little evidence exists in this study which enables the assertion of 
Mirowsky and Ross (1984) that Mexican culture buffers Mexican- 
Americans from anxiety but makes this population relatively suscept- 
ible to depression. If the assertion were valid, one would expect a 
positive standardized regression coefficient between Mexican accul- 
turation and depression, controlling for SES, and a negative coeffi- 
cient between Mexican acculturation and anxiety. Findings presented 
in sub-Tables 2a and sub-Table 3a, however, indicate a positive and 
statistically significant association between Mexican acculturation 
and each form of psychological distress. 

As noted above, neither ethnicity nor SES remain statistically sig- 
nificant as determinants of depression and anxiety after all relevant 
variables are entered into multiple regression equation (sub-Table 
2c and sub-Table 3c). We do not interpret these findings to mean that 
sensitivity to ethnicity and socioeconomic background is clinically 
unimportant. Problems of colinearity and concomitant false nega- 
tive results in multiple regression analysis have been discussed above 
and will not be repeated here. But more to the point, we suggest that 
clinicians not interpret these findings as a call to ignore Mexican- 
American and Anglo cultural differences. The difficulty that Mex- 
ican-American patients have in approaching institutional caretakers 
has been noted by clinicians to arise because of problems in perceiv- 
ing any possible benefits from these services, as well as a frank mis- 
trust of the clinical setting (Bach-y-Rita, 1982). These problems, 
however, are most likely associated with under-class Mexican- 
Americans. This assertion is indirectly supported by findings from 
a study (Quesada et al., 1977) of board membership lists from com- 
munity mental health service agencies in San Antonio, Texas. 
Although a high proportion of board members possessed Spanish 
surnames, virtually all of these persons lived in high income census 
tracts. Thus, it appears that high SES does mitigate many of the ef- 
fects of minority status by placing persons in a structurally presti- 
gious and affluent network of relationships and associational 
memberships. On the other hand, cultural sensitivity should be an 
integral part of any therapeutic relationship, and especially for 
under-class Mexican Americans, the need for bilingual clinicians and 
support staff speaks for itself. Nevertheless, our findings suggest that 
overemphasis on so called Mexican cultural factors may comprise 
a waste of scarce resources and indeed may be perceived as patroniz- 
ing by Mexican-American individuals. 



Factors Associated with Psychological Distress 101 



Our findings (Table 1 , and sub-Table 2a and sub-Table 2b) do sug- 
gest that under-class marginality, rather than Mexican- American sta- 
tus per se, may constitute the important inhibiting factor in 
help-seeking behavior and good therapy. In this respect, there ap- 
pears to exist the need for less bureaucratic, neighborhood oriented 
mental health care emphasizing traditional mental health center con- 
cepts. Clinics could provide outreach programs that establish net- 
works, with existing community associations such as church, 
neighborhood social clubs and sport leagues. 

If nothing else, our findings indicate a need to move beyond the 
minority status-ethnic culture debate, in terms of a multifactorial ap- 
proach to psychological distress, both for Anglos and Mexican- 
Americans. A multiplicity of variables — sometimes independently, 
but mostly in combination — produce a particular disorder. We feel 
that our findings strongly refute arguments that emphasize a single 
dominant factor over others. In addressing the clinical problems seen 
in mental health facilities serving Mexican-American and under-class 
patients, factors other than ethnicity and SES must be considered. 
For example, it is essential that the clinician relevant factors are con- 
sidered, in terms of the ways in which these factors (e.g., personal 
distress symptomatology) interact with each other within a wide 
range of psychosocial antecedents to contribute to the production 
of a psychiatric disorder. 

More specifically, our findings strongly reinforce the need for the 
multiaxial evaluation system suggested by DSM-III-R (American 
Psychiatric Association, 1987), especially Axis IV and V. (Axis IV 
refers to severity of psychosocial stressors). Assessment of life stress 
and degree of financial hardship is currently a common part of the 
clinician's work-up procedure but often is not determined as a con- 
tinuum. Inclusion of a series of specific life stress questions, and an 
assessment index concerning the patient's material well-being, could 
be included during the initial evaluative stages of treatment. A simple 
summing of these indices would allow the practitioner to more ac- 
curately quantify severity of stress, while specifying critical economic 
hardship issues. Regarding the need cited by DSM-III-R, Axis V for 
a more global assessment of functions, we feel it is vital to assess the 
patient's possession of meaningful support network and perceived 
mastery over the immediate environment. And in line with DSM-III- 
R philosophy, these factors are measured in terms of degree rather 
than as either/or dichotomies. The term meaningful support is not 



1 02 Latino Mental Health 



issued lightly. Work-up questions or scales concerning degree of sup- 
port should cover the extent to which a client possesses a familial, 
peer, and/or institutional network that serves as a resource for 
specific socio-emotional and/or economic exigencies encountered in 
everyday life. As noted previously, immersion within a web of kin 
members is not necessarily an indication of positive support. 

Regarding gender, female status tends to bring with it a relatively 
high level of depression and anxiety. Even after controlling for rele- 
vant variables (sub-Table 2c and sub-Table 3c), females tend to be 
more depressed and anxious than their male counterparts. These 
findings are consistent with recent Epidemiologic Catchment Area 
(EC A) prevalence rates of major depressive episode and anxiety dis- 
orders (Regier et al., 1988). We interpret these findings to mean that 
sociocultural conditions faced by women are in themselves capable 
of producing relatively high levels of anxiety. 

Finally, the setting for this study is El Paso, Texas, a border com- 
munity with large populations of Mexican-Americans and Anglo- 
Americans. The demographic characteristics of the area, which in- 
clude the existence of dynamic migrant patterns, provide a fertile 
ground for the study of acculturation and its impact on the clinically 
relevant variables addressed in this study. In agreement with 
Yamamoto and Silva (1987), we feel that further research in this area 
should be longitudinal in nature and compare border with nonborder 
populations. Our study, which explores psychosocial factors as de- 
terminants of psychological distress, needs to be enlarged into a 
research model that analyzes how expanded hierarchical variable sys- 
tems interact in producing psychopathology within and across eth- 
nic groupings. Future research should integrate macro level and 
biopsychosocial variables, compare border and nonborder popula- 
tions, be longitudinal in nature, and tested simultaneously on more 
than one ethnic grouping. 



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Factors Associated with Psychological Distress 103 



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391-403. 






Part II 



Assessment 









Latinos and the Expression of 

Psychopathology: A Call for the 

Direct Assessment of Cultural Influences 

Steven Regeser Lopez 



Many authors have encouraged mental health clinicians to take 
culture into account when evaluating and treating patients from 
diverse cultural and ethnic backgrounds residing in the United States 
(Sue & Sue, 1990; Pedersen, Draguns, Lonner & Trimble 1989; and 
Levine & Padilla, 1980). These authors argue that modifications in 
usual clinical assessment and intervention procedures are needed be- 
cause there are important cultural differences between the dominant 
Anglo culture and the diverse minority cultures. Further, it is be- 
lieved that if clinicians fail to consider the shared beliefs, values, and 
practices of the patient's cultural group, and if clinicians fail to 
modify their clinical practice accordingly, then people of color will 
likely be misdiagnosed and given improper treatment (Malgady, 
Rogler, & Costantino, 1987). Thus, the rationale for developing cul- 
turally sensitive clinical services is based in part on the notion that 
there are important cultural differences in the psychopathology of 
cultural minorities. 

The importance of cultural factors within the mental health fields 
appears to be gaining widespread acceptance. This is evident in an 
increasing number of books published in this area (Comas-Diaz & 
Griffith, 1988), in an increasing number of conferences and work- 
shops on this topic, and in an increasing number of articles in 
scholarly journals as reflected, for example, in the special issues of 
the British Journal of Psychiatry (1990), Hospital and Community 
Psychiatry (1988), and the Journal of Consulting and Clinical 
Psychology (1986). 

Despite the growing recognition of the role of culture in psy- 
chopathology, it is worth noting that the empirical basis to this area 
of study, particularly for Latinos, is at best limited. Fabrega (1990) 
recently argued that mental health research concerning Latinos ad- 
heres to "establishment" paradigms, thus restricting its ability to 



1 1 Latino Mental Health 



identify cultural influences in psychopathology. Measures of distress 
and disorder, for instance, have been taken from mainstream 
research with little if any modification for use in studying Latinos. 
Guarnaccia, Good, and Kleinman (1990) make a similar argument 
and point out the need to incorporate "indigenous categories of ex- 
perience" within available epidemiologic measures. 

Because of the limited data, an important rationale for develop- 
ing culturally sensitive mental health services for Latinos is without 
adequate empirical support. In an effort to encourage further 
research, I review and critique representative studies of cultural in- 
fluences in the expression of psychopathology of Latinos. Recent in- 
vestigations of psychiatric epidemiology are among those reviewed. 
Studies of language influences in the expression of psychopathology 
are not included. 

Without the empirical basis to identify cultural factors in the ex- 
pression of psychopathology of Latinos, clinicians have the option 
of ignoring cultural influences or trying to take them into account 
without empirical guidelines. There is evidence that they are choosing 
the latter. A survey of mental health professionals found that they 
value the importance of culture in their work with ethnic minorities 
and are attempting to take such factors into account (Lopez & Her- 
nandez, 1986). Without empirically based guidelines, however, they 
may apply their own cultural assumptions. Lopez and Hernandez 
found evidence that, when considering cultural factors, clinicians are 
at risk for minimizing actual psychopathology, because they believe 
the specific symptoms or disorder are reflective of culturally norma- 
tive behavior. A strong empirical database of culture and psycho- 
pathology could contribute to correcting these and other potential 
errors in the evaluation and treatment of Latinos. Until there is such 
a database, however, guidelines are needed to assist clinicians in 
deciphering the cultural influences in the expression of psychopathol- 
ogy. Another objective is to review available research regarding how 
clinicians consider cultural factors in their clinical practice and, 
drawing from this research, to present guidelines for clinicians 
on how to consider cultural factors in their clinical evaluations 
of Latinos. 

Researchers and clinicians are essentially asking the same ques- 
tions: What is the meaning of a given clinical phenomenon, whether 
it is a set of responses to a diagnostic research instrument (e.g., The 
Diagnostic Interview Schedule), or observations based on a clinical 
interview? Is the identified phenomenon reflective of psychopathol- 



Latinos and the Expression of Psychopathology 1 1 



ogy, culturally normative beliefs, or some combination of the two? 
My overall aim is to encourage both investigators and practitioners 
to directly assess cultural influences in psychopathology. By doing 
so, they will be less likely to apply cultural assumptions and more 
likely to identify true cultural influences in the psychopathology of 
Latinos. 

The definition of culture used herein refers to the subjective ele- 
ments of culture (Triandis, 1972), specifically the roles, values, and 
beliefs shared by a people or a particular segment of the population. 
Another way of stating this is that culture reflects the systems of 
meanings which are learned and shared by a particular group (Roh- 
ner, 1984). The study of culture and psychopathology then concerns 
how these systems of meanings are related to psychological distress 
and disorder. 

Culture and the Expression of Psychopathology 

Early research in Latino mental health identified several instances 
of how the Latino culture may influence the expression of psy- 
chopathology and related normative behavior. Latinos have been 
reported to somaticize their psychological distress (Stoker, Zurcher, 
& Fox, 1969), to present their distress as folk illnesses (e.g., susto 
or nervios) (Fernandez-Marina, 1961; Rubel, 1964), and to hear 
voices that do not necessarily reflect hallucinations (Torrey, 1972). 
There is little doubt that these phenomena occur. Because the early 
findings were based on clinical observations and/or studies with 
small nonrepresentative samples, the degree to which the results ap- 
ply to Latino communities in general was not known. 

Large scale epidemiologic surveys of psychological distress 
(Roberts, 1980; Vega, Warheit, Buhl-Auth, & Meinhardt, 1984) and 
mental disorders (Canino, Bird, Shrout, Rubio-Stipec, Bravo, Mar- 
tinez, Sesman, & Guevara, 1987; Karno, Hough, Burnam, Escobar, 
Timbers, Santana, & Boyd, 1987) have been able to address the 
representativeness of some of the previously noted findings. The use 
of systematic sampling methods and instruments with demonstrated 
reliability and some validity contributed to enhancing the quality of 
this research. Further, with the inclusion of measures of accultura- 
tion among some of this research, there was hope that these inves- 
tigations would be able to identify the manner in which cultural 
factors might influence the examined distress and disorders. 

There is little doubt that this research, some of it discussed in this 
book by Canino, Escobar, Karno, Telles, and Vega, respectively, has 



1 1 2 Latino Mental Health 



made a most significant contribution to Latino mental health. As 
a result of these efforts, we have considerable information regard- 
ing the prevalence rates of psychological distress and many mental 
disorders among several Latino communities, as well as factors as- 
sociated with these rates (e.g., immigration status). Further, because 
of the use of accepted state-of-the-art measures, such as the Diag- 
nostic Interview Schedule (DIS) and the Center of Epidemiologic 
Studies — Depression Scale (CES-D), we can compare the obtained 
rates of Latinos with those from other populations, such as Euro- 
Americans and African- Americans, to assess the relative prevalence 
rates. 

Although the noted epidemiologic investigations have made im- 
portant contributions, this research has been limited in identifying 
cultural influences in the psychopathology of community samples. 
First, direct measures of culture, such as cultural norms or beliefs, 
have rarely been used. In a study by Mirowsky and Ross (1984) for 
example, the authors included a measure of locus of control; 
however, the instrument was not derived from studies of culture since 
it originated from the study of individual differences. As a result, 
it is unclear whether or not it is an accurate or specific measure of 
culture. Instead, researchers frequently interpret ethnic differences 
as reflecting cultural differences (Escobar, Burnam, Karno, For- 
sythe, & Golding, 1989). Second, the use of acculturation measures 
as a proxy cultural measure is limited because the meaning of accul- 
turation effects is unclear. Such effects can reflect adherence to tradi- 
tional cultural values, acculturative stress, language factors, selective 
migration or a combination of these other factors (Berry, 1990; 
Golding & Burnam, 1990). Third, researchers primarily use diagnostic 
entities or distress summary scores as the main dependent measures, 
although there are notable exceptions (Guarnaccia, Rubio-Stipec, 
& Canino, 1989; Escobar, Rubio-Stipec, Canino, & Karno, 1989). 
Diagnostic measures may be less sensitive to sociocultural influences 
than symptom-based measures of psychopathology. I will point out 
how these three factors have limited past research in identify- 
ing cultural influences along with offering recommendations on 
how future research can position itself to better identify cultural 
influences. 

Indirect Assessment of Cultural Influences 

The statistical methods most frequently used in the study of Latino 
psychopathology have been regression models that compare the rates 
of two ethnic groups, usually a specific subgroup of Latinos and 



Latinos and the Expression of Psychopathology 1 1 3 



Euro- Americans. The focus of the research is to assess whether there 
are ethnic differences in prevalence rates or symptomatology. Be- 
cause ethnicity is usually related to other sociodemographic factors, 
such as socioeconomic status, religious background, and age, steps 
are taken to control for these other factors. If ethnic differences still 
remain after applying statistical controls, then cultural factors are 
oftentimes implicated. For example, in the study of somatization 
among Mexican Americans, cultural explanations have ranged from 
generally pointing out that unspecified cultural factors might explain 
these differences (Escobar et al., 1987) to specifically point out how 
the Mexican American culture leads to the expression of gastro- 
intestinal symptoms and the Anglo-American culture leads to the 
report of headaches (Stoker, Zurcher, & Fox 1969). 

The weakness of this approach is that no direct measure of cul- 
tural beliefs and values are included in the research, as noted by 
Roberts (1980). As a result, it is difficult to confirm whether certain 
symptomatology or disorders are indeed culturally related. Without 
a direct measure of culture, one can at best say that the findings are 
consistent with a cultural hypothesis, nothing more. 

The direct measure of cultural values has specific analytic advan- 
tages. In a cross-ethnic study, one can assess whether the two eth- 
nic samples differ on a specific cultural value, rather than assume 
they do differ. That is, by including a culture measure such as 
religiosity and spirituality in an epidemiologic study of Latinos and 
Euro- Americans, one can directly test whether the two groups differ 
on this dimension. But it is important to note that by including direct 
measures of cultural beliefs and values, the investigator can test 
whether cultural beliefs mediate the relationship between ethnicity 
and psychopathology. For example, let us assume that a measure of 
spirituality was included in an epidemiologic study that found 
Latinos to report hearing voices more than Euro- Americans. The 
relationship between ethnicity, spirituality and hearing voices could 
then be assessed. Of particular interest would be testing a media- 
tional model (Baron & Kenny, 1986) in which ethnicity is the 
predictor variable, hearing voices is the criterion variable, and 
spirituality is the mediating variable. Support for this model would 
be found if spirituality was found to be related to hearing voices, and 
if controlling for spirituality lead to a non-significant relationship 
between ethnicity and hearing voices. This pattern of findings would 
directly support the notion that the cultural value of spirituality un- 
derlies the observed ethnic difference in hearing voices. 

The inclusion of cultural measures is also of considerable value 



1 1 4 Latino Mental Health 



when studying only one ethnic group. One would expect variability 
on a given cultural measure, such as spirituality. This would then 
provide the investigator an opportunity to examine whether that 
cultural measure is related to the phenomenon of interest. For ex- 
ample, the relationship of spirituality to hearing voices could be ex- 
amined in a study of only Puerto Ricans or of only Euro- Americans. 
It is important to note that cultural influences can be examined 
within majority and minority groups. Too often investigators have 
only implicated cultural factors for ethnic minority groups. The psy- 
chopathology of majority groups is also culturally influenced. The 
important point here is that by measuring cultural values and beliefs 
directly, cultural influences in the psychopathology of Latinos and 
other groups can be assessed. 

Some Limitations of Acculturation Measures 

To examine possible cultural influences, some investigators have 
used measures of acculturation. This approach is an improvement 
over merely examining ethnic differences and controlling for other 
variables, such as socioeconomic status. If acculturation can account 
for a significant proportion of the variance in the measures of dis- 
tress or disorder among Latinos, then a stronger case can be made 
for a cultural interpretation than when only an ethnic difference is 
found. Even then, it is questionable whether acculturation indices 
reflect adherence to cultural values or norms. 

Acculturation measures are at best only approximate measures of 
culture. The acculturation indices used to date typically are based 
on generation born in the United States and various behavioral in- 
dicators, such as language usage and ethnicity of friends. These are 
not direct measures of the specific cultural values and beliefs that 
are likely to underlie expressions of psychopathology. Instead, those 
investigators who use these measures assume that individuals of low 
acculturation are more likely to adhere to traditional cultural values 
regarding such variables as gender roles, familism, spirituality and 
collectivism/individualism. This assumption may or may not be true 
for a given sample. Therefore, it is important to include measures 
of values or beliefs, in addition to measures of acculturation. 

Another reason why acculturation is a poor measure of cultural 
influences is that it is confounded with acculturative stress, or the 
stress experienced as people from one culture adjust to another cul- 
ture (Berry, 1990). Some investigators have attempted to determine 
whether certain levels of acculturation are related to psychological 



Latinos and the Expression of Psychopathology 1 1 5 



distress and rates of mental disorders. The findings with regard to 
Latinos are mixed. Some studies find more distress among the less 
acculturated, others among the more acculturated, and still others 
among those that fall between the assumed poles of high and low 
acculturation (Rogler, Cortes and Malgady, 1991). Whatever the 
finding, it is not reasonable to interpret these findings solely as ac- 
culturative stress. It seems possible that they could also reflect the 
association between specific cultural values, indirectly assessed, and 
level of distress or rates of disorders. Without directly assessing cul- 
tural values and beliefs, and without directly assessing acculturative 
stress, it is difficult to know the meaning of significant relationships 
between acculturation and psychopathology. The recent develop- 
ment of the Hispanic Stress Inventory (Cervantes, Salgado de Snyder 
& Padilla, 1991) may contribute to identifying the distinct effects of 
acculturation and acculturative stress on psychopathology. 

Unit of Analysis 

Another reason why few cultural influences in the psychopatho- 
logy of Latinos have been identified is that the typical unit of ana- 
lysis is somewhat removed from direct sociocultural influences. With 
regard to the assessment of prevalence rates of disorders, Karno et 
al. (1987) reported many more ethnic similarities than differences. 
Canino et al. (1987) also reported many similarities in the prevalence 
rates of disorders for Puerto Rican Islanders relative to the other 
U.S. mainland sites in epidemiologic studies. The identification of 
disorders is based on multiple criteria with inclusionary and exclu- 
sionary rules, several steps removed from the symptom, the basic 
unit of psychopathology. Disorders may not be as sensitive to the 
influence of the underlying sociocultural processes as symptoms 
might be (Draguns, 1980; Persons, 1986). 

Several studies suggest the importance of symptoms in identify- 
ing cultural factors. Guarnaccia et al. (1989) derived an 'ataque de 
nervios' syndrome based on 12 symptoms from the somatization dis- 
order of the DIS and data from the Puerto Rican Island epidemio- 
logic study. Rubio-Stipec, Shrout, Bird, Canino and Bravo (1989) 
conducted factor analyses on the symptoms from the major diag- 
nostic categories of the DIS and derived symptom factors for the 
Puerto Rican Island study and the Los Angeles Epidemiologic 
Catchment Area (ECA) study. Symptom-based analyses also have 
been conducted for somatization (Escobar et al., 1987) and depres- 
sion (Garcia & Marks, 1989; Golding & Aneshensel, 1989; Golding, 



1 16 Latino Mental Health 



Karno, & Rutter, 1990). Except for the symptom measures used to 
derive an assessment of "ataque de nervios," for which ethnic group 
differences were not assessed, the symptom-based research appears 
to have uncovered ethnic differences to a greater degree than the 
disorder-based analyses. Similar to the disorder based studies, 
however, many more ethnic similarities have been identified than eth- 
nic differences. Most importantly, all of these findings are limited 
in that no direct measure of culture was used. Therefore, it is difficult 
to know the extent to which such ethnic differences are culturally 
based. 

A study that demonstrates the importance of symptom analysis 
and attempts to test directly cultural hypotheses was recently carried 
out by Lopez, Hurwicz, Karno and Telles (1992). In this study, we 
examined the distribution of schizophrenic and manic symptoms 
among the Mexican origin and Anglo samples of the Los Angeles 
EC A. Karno et al. (1987) had reported that there were no significant 
ethnic differences in the prevalence rates of these two disorders. 
Lopez et al. (1992), however, found consistent ethnic/immigration 
status differences in manic symptomatology. For example, Mexican- 
born Mexican respondents reported less hypersexuality (2.2%) than 
U.S. -born Mexicans (4.3%), who reported less than Anglos (6.8%). 
In addition, among the schizophrenic symptoms, auditory halluci- 
nations were found to be more often reported by Mexican origin 
respondents (Mexico-born Mexicans: 2.3%; U.S. -born Mexicans: 
1.6%) than by Anglos (0.6%). Based on prior observations that sug- 
gested the role of religiosity for both symptoms (Torrey, 1972), we 
attempted to approximate a direct cultural test by examining the rela- 
tionship between religiosity and symptoms. Regression analyses re- 
vealed that ethnicity is significantly related to the reporting of 
hypersexuality and that Catholicism mediates this relationship. Eth- 
nicity is also related to hearing voices; however, religious affiliation 
was not found to be a mediator of this relationship. It may be that 
the report of auditory hallucinations is more related to spiritual be- 
liefs that may exist independently of religious background. 

Although this research goes beyond the typical comparative eth- 
nic study by examining specific sociocultural factors that are related 
to symptomatology, it falls short of the ideal study. Catholicism is 
an important variable, but it does not capture actual values and be- 
liefs. Measuring beliefs and attitudes about sexual relations would 
have provided a more direct assessment of cultural influences. 



Latinos and the Expression of Psychopathology 117 



Another limitation is that the relationship between Catholicism and 
hypersexuality may reflect reticence on the part of Catholics to report 
this symptom, not their relatively lower level of sexual activity. 
Despite its weaknesses, this study illustrates the importance of as- 
sessing symptoms instead of disorders and of attempting to identify 
the sociocultural factors that underlie ethnicity. 

Summary 

Past clinical research and recent epidemiologic research has 
provided little indication of cultural influences. First, it is important 
that future research incorporate direct measures of culture, that is, 
measures of specific values or beliefs that are hypothesized to be 
related to the sign, the symptom, the distress, or the disorder under 
study. Second, acculturation measures should be incorporated in this 
research for clearly specified purposes, rather than as global mea- 
sures of culture. Accordingly, if acculturative stress, for example, 
is central to the study's aim, then the assessment of acculturative 
stress should be a priority. Third, additional attention should be 
given to symptoms as the unit of analysis. In conjunction with the 
recommendations of Fabrega (1990) and Guarnaccia et al. (1990) to 
use more culture-specific approaches to studying populations of 
Latinos, these three steps should also contribute to improving the 
ability of researchers to identify cultural influences in the psycho- 
pathology of Latinos. 

Clinicians' Consideration of Cultural 
Factors in Evaluations 

Steps to improve the research concerning Latinos' expression of 
psychopathology will no doubt contribute to enhancing clinicians' 
consideration of cultural issues in their evaluation and treatment of 
this group. Clinical guidelines based on psychopathology research 
could be developed one day to assist practitioners in grappling with 
cultural issues when working with Latinos. Because of the limitations 
of available research, and because of the push for clinicians to con- 
sider cultural factors in their clinical practice, it is important to learn 
if and how clinicians are taking culture into account. One concern 
is that mental health professionals are applying cultural stereotypes 
in an effort to be culturally responsive. Although there is little sys- 
tematic evidence as to what may or may not be cultural in nature, 
studying practitioners' use of cultural concepts may shed some light 



1 1 8 Latino Mental Health 



on how such concepts should be applied. Specifically, by examin- 
ing the clinical judgment process by which cultural factors are con- 
sidered, an evaluation of the process can be made. 

To examine how clinicians deal with the dilemma of considering 
cultural factors without applying cultural stereotypes, I review per- 
tinent research regarding mental health professionals' consideration 
of cultural factors in their clinical evaluations. I organize this 
research around two questions: Do clinicians consider cultural fac- 
tors? and What effect does their consideration of culture have on 
their clinical judgments? I draw from available case studies, survey 
research, and experimental studies. Based on this brief review, I offer 
guidelines on how best to take culture into account in evaluations 
of Latino patients. Much like my recommendations for psycho- 
pathology researchers, I encourage clinicians to directly assess cul- 
tural hypotheses. 

Do Clinicians Consider Cultural Factors? 

A number of sources indicate that mental health professionals are 
considering cultural factors in their evaluation and treatment of 
Latino patients. Clinicians have written about specific cases delinea- 
ting how they have taken culture into account. For example, Cuellar, 
Martinez, Jimenez, and Gonzalez (1983) described their consider- 
ation of linguistic and cultural factors in the differential diagnosis 
of schizophrenia and major depression. Many other clinical ob- 
servers have pointed out the manner in which they consider cultural 
issues (Comas-Diaz, 1981; Morales, 1982; Munoz, 1981). Together, 
the clinical case reports indicate that clinicians do indeed consider 
cultural issues. Further, they reveal how mental health professionals 
modify their assessment, intervention, or both as a result of recog- 
nizing the cultural elements. It is unclear, however, to what extent 
clinicians other than the authors themselves consider cultural fac- 
tors in their clinical practice. 

Recent research conducted by me and my colleagues suggest that 
cultural considerations extend beyond the case reports in the clini- 
cal literature. In one mail survey of 1 18 licensed social workers, psy- 
chiatrists and psychologists practicing in California, 83% indicated 
that they take culture into account for most or all of their culturally 
diverse patients. In addition, they rated culture as very important; 
on a 1-9 scale anchored by the poles "not at all important" and "ex- 
tremely important", their mean rating was 7.5. 

In two independent studies of clinical judgment, two Southern 



Latinos and the Expression of Psychopathology 1 19 



California samples of mental health professionals (n = 96; n = 72) 
reported that they considered the cultural background of the patient 
depicted in the clinical stimuli. In one investigation (Lopez, 1983), 
the clinical stimuli comprised six, one-page case reports from actual 
patients representing a wide range of psychopathology. We manipu- 
lated the ethnic label of the cases so that, in one condition, a given 
case was identified as Mexican and, in the other condition, the case 
was identified as Anglo. Clinicians rated the degree to which each 
case was due to the patient's cultural background. When the cases 
were identified as Mexican, clinicians attributed the presenting 
problem significantly more to a patient's cultural background than 
when identified as Anglo. For example, in the case of a dependent 
wife, when identified as Mexican, the mean cultural attribution rat- 
ing was 6.57 on a scale of 1 - 9 ("not at all" to "very much due to 
cultural background"). When identified as Anglo, the corresponding 
mean rating was 4.78. In the second study (Lopez, Magana, & Nu- 
nez, 1992), a videotape of an enacted clinical interview served as the 
clinical stimulus. Based on an actual case, an actress portrayed a 
Mexican-American female patient reporting among other things 
physical symptoms, depressed mood and marital distress. Again, 
culture was implicated to a considerable extent (mean ratings varied 
between 5.47 to 6.18 on the same 1-9 scale). 

Altogether, the case studies and the three research studies converge 
to indicate that mental health practitioners are taking cultural fac- 
tors into account. The research does have its limitations. Asking 
practitioners about their perceptions of the cultural nature of the 
problem may have heightened the attention of clinicians to culture, 
thus leading them to consider cultural factors to a greater degree than 
they actually do in their clinical work. Furthermore, the represen- 
tativeness of the samples of practicing clinicians is open to question. 
For example, the response rate of the survey study was 40.8%; those 
who did not respond may view culture as less important than those 
who did respond. Despite these and other limitations, the best avail- 
able evidence indicates that clinicians are indeed trying to consider 
cultural factors in their clinical work. 

Impact of Cultural Considerations 

Although it is important to know that clinicians may be taking cul- 
ture into account, it is particularly important to assess the influence 
such considerations have on clinical practice. In an effort to examine 
this question, my colleagues and I have focused our attention on the 



1 20 Latino Mental Health 



clinical judgment process. Specifically, we have examined whether 
taking culture into account leads clinicians to judge patients as hav- 
ing more or less pathology than when cultural factors are not con- 
sidered. The available findings suggest that considering culture is a 
complex process which is not easily characterized in terms of its im- 
pact on clinical judgment. In this section, I review the available sur- 
vey and experimental research which is comprised of other aspects 
of previously mentioned studies. 

For the Lopez and Hernandez (1986) survey, clinicians were asked 
to describe a time when they took cultural factors into account in 
their evaluation of a particular patient. Most respondents provided 
a brief case report (n = 96) in which a wide range of ethnic groups 
were represented among the cases, Latinos being the ethnic group 
most represented (n = 35). Refer to Lopez (1987) for a closer exami- 
nation of the cases of Latinos. These vignettes were subsequently 
analyzed with regard to what effect considering culture had on judg- 
ments of clinicians. One finding of interest is that for 61 cases, 
almost no mention of clinical judgments or diagnoses was made, 
despite the specific request to describe an experience of evaluating 
and/or diagnosing a culturally diverse patient. Although the respon- 
dents indicated that they did not alter their judgments as a result of 
taking culture into account, they did note that, in considering cul- 
tural factors, they more fully understood the presenting problem, 
they were better able to define the treatment goal, and they were able 
to alter the treatment in some fashion that they thought led to more 
effective care. Thus, for most clinicians, considering culture did not 
influence their clinical judgment. One interpretation of this finding 
is that clinicians may more readily take culture into account in areas 
other than their clinical assessment (e.g., intervention). 

There were some clinicians, however, who did report that they 
changed their judgments following their cultural considerations. In 
fact, thirty-five clinicians, a bit more than one third of the sample, 
acknowledged doing so. Three stated that they judged the problem 
to be more severe or more resistant to change as a result of taking 
culture into account. The following vignette represents this view: 

"A 60-year-old Mexican alcoholic VA outpatient. Dependency 
needs with (his) family members were huge. If he were Anglo- 
Saxon, an attempt to deal with alcohol dependency alone might 
have had a chance of success" (Lopez & Hernandez, 1986, p. 
605). 



Latinos and the Expression of Psychopathology 121 



The practitioner here notes that because of the patient's ethnic back- 
ground, an intervention is not likely to be successful. 

The other thirty-three respondents who reported having changed 
their judgments in some fashion indicated that they judged the 
problem to be less serious as a result of taking cultural factors into 
account. One such example is: 

"In my work with a particular Hispanic female, my judgment 
of her ego strength or self-image was quite different than it 
would have been had I not taken into account cultural patterns 
which "condoned" the male being unfaithful and having other 
relationships. Accepting this practice is not considered a devi- 
ant choice in a female of the Hispanic culture" (Lopez & Her- 
nandez, 1986, p. 603). 

This mental health professional adjusted evaluation of the patient 
from having a poor self-image to having a normal self-image. The 
rationale of the clinician for this change was that extra-marital rela- 
tionships are an accepted practice for Latinos. In other words, be- 
cause of the perception of the psychotherapist that this practice 
reflected the norm for the Latino culture, the patient's reaction to 
her husband's behavior was not judged to be a problem. In sum- 
mary, this study found that in most cases clinicians did not adjust 
their clinical judgment when considering cultural factors. When they 
did, however, they primarily judged the presenting problem to be 
less severe. Only on a few occasions were patients judged to be more 
disturbed because of the cultural perspective of the clinician. 

The experimental study in which clinicians rated brief case reports 
(Lopez, 1983) provides further evidence of varied effects of consider- 
ing culture, particularly for the three cases which clinicians viewed 
as most related to cultural factors. Practitioners judged a case of a 
Mexican adolescent male with a gang-related problem as reflecting 
less disturbance and requiring less treatment the more they judged 
the problem to be related to his culture. The findings were reversed 
for the case of a dependent, passive wife, with marital problems. 
Clinicians judged the problem as more serious and as requiring more 
treatment as they attributed the problem to a patient's Mexican cul- 
tural background. In a third case, one in which a middle-aged mother 
felt unfulfilled, particularly after her children had left home, the 
clinicians' attributions to the patient's Mexican culture were un- 
related to their clinical judgments. Like the previous study, the find- 
ings were mixed with regard to the relationship between the 



1 22 Latino Mental Health 



practioners' considerations of cultural factors and their clinical 
judgments. This study suggests that the presenting problem may 
be important to how cultural attributions and clinical judgments 
are related. 

A mixed pattern of results was also found in the second ex- 
perimental study in which clinicians were presented with a videotaped 
clinical interview of the depressed, married, Mexican American 
woman (Lopez, Magana, & Nunez, 1992). One set of findings re- 
vealed that the more clinicians viewed the patient's marital conflict 
and somatization as culturally based, the more serious they judged 
the patient's marital conflict and somatization to be. In this case, 
clinicians' consideration of culture led to the perception of more 
pathology. With regard to clinicians' judgment of the severity of her 
depression, cultural attributions were found to be unrelated. In other 
words, ratings of the severity of depression did not change as a func- 
tion of clinicians' considerations of the patient's culture. 

Taken together, the available evidence indicates that taking cul- 
ture into account is related to a set of mixed outcomes in clinicians' 
judgment. On some occasions, considering culture is related to judg- 
ments of less pathology. On other occasions, it is related to judgments 
of more pathology; yet, on other occasions, there is no observed rela- 
tionship between cultural attributions and clinical judgments. This 
divergent pattern of findings can be viewed as either revealing very 
little, that is, the findings appear to be random: some supporting the 
notion of a minimizing bias (judgments that there is less pathology 
than is the case); others supporting the notion of an overpathologiz- 
ing bias (judgments that there is more pathology than is the case); 
and still others supporting the notion of no bias. Conversely, these 
results can be interpreted as reflecting the complex ways that cultural 
considerations can relate to judgments of clinicians. At this early 
stage of research, I take the latter view that the findings reflect com- 
plexity. It seems very possible that considering culture can influence 
the evaluations of clinicians in many ways. 

One limitation of this research is that it is not known if such ad- 
justments in clinical judgment reflect an accurate assessment of cul- 
ture's influence or the application of cultural stereotypes, which may 
result in judgment bias or error. Although it is possible that such ad- 
justments of clinical judgment reflect an accurate assessment, the 
fact that there is nothing in the clinical stimuli to warrant such ad- 
justments suggests that they represent possible error. Just because 
the patient is described as Mexican does not indicate that a given 
presenting problem reflects more or less disturbance. Additional evi- 



Latinos and the Expression of Psychopathology 123 



dence about the patient's cultural values and beliefs is needed be- 
fore such modifications can be made. Also, the seemingly stereotypic 
ways that some clinicians reported taking into account culture as sug- 
gested by the vignettes supports the possibility of error. Given this 
perspective, the data suggest that as practitioners consider cultural 
factors in their evaluations of Latino patients, they are at risk for 
seeing less pathology or seeing more pathology than might be the 
case. Ctearly, further research is needed to examine the conditions 
that most affect clinical judgment as clinicians consider the patient's 
cultural background. Of most importance is to include some gold 
standard as to what is the correct clinical judgment so that the ob- 
served judgments can be identified as accurate or as inaccurate. A 
similar perspective regarding the complexities in assessing whether 
or not patient variables such as gender, race, social class, etc. elicit 
biases in the judgments of clinicians is described by Lopez (1989). 

Implications for Clinical Practice 

The available findings on clinical judgment and cultural considera- 
tions indicate that clinicians are attempting to be responsive to the 
cultural values and beliefs of patients. Furthermore, their consider- 
ations of culture are at times related to their clinical judgment. 
Although it is important for clinicians to take culture into account 
in evaluating and treating Latino patients, it is important to do so 
carefully. The distance between cultural responsiveness and cultural 
stereotyping can be short. 

There are a number of steps that clinicians can take to reduce the 
risks of error in considering the cultural context. The first is to recog- 
nize the considerable heterogeneity among Latinos. Socioeconomic 
status, generational status, language use, national origin, rural or 
urban background, etc. can be relevant variables in determining the 
applicability of specific cultural notions. Second, it is important that 
clinicians consider cultural notions as hypotheses, rather than fact, 
and that they test the hypotheses. For example, when considering 
that somatic complaints may reflect a culturally acceptable way of 
presenting psychological distress, the clinician can collect a detailed 
history of the course of the somatic complaints to see if their onset 
and offset correspond to periods of considerable stress. If this is the 
case, then the somatic complaints might be a culturally patterned 
form of expressing distress. In addition, the clinician might do best 
to assess the meaning that the patient and significant others ascribe 
to the physical symptoms. If this is an unusual symptom or set of 
symptoms that others rarely if ever experience, then such evidence 



124 Latino Mental Health 



would go against a cultural hypothesis. On the other hand, if this 
presenting problem is relatively commonplace and has a specific 
meaning, then this would suggest cultural factors. In addition to as- 
sessing the cultural nature of the somatic complaints, a third step 
is to entertain alternative hypotheses. In this case, a reasonable al- 
ternative hypothesis is that the somatic complaints reflect a true 
physical disorder. Thus, a thorough medical examination would be 
required. In sum, being cautious in implicating cultural factors, 
generating and testing specific cultural hypotheses, and examining 
alternative hypotheses should serve to reduce the likelihood that 
clinicians misapply cultural explanations in working with Latino 
patients. For further discussion refer to Lopez, Grover, Holland, 
Johnson, Kain, Kanel, Mellins, and Rhyne (1989). 

Conclusion 

There is considerable overlap with regard to the ways both 
researchers and clinicians can better assess cultural influences in the 
psychopathology of Latino patients. Both professional groups need 
to go beyond ethnicity as an indicator of culture. At best, ethnicity 
can only suggest plausible cultural hypotheses that require indepen- 
dent evaluation. To test possible cultural influences, both researchers 
and clinicians should push themselves to identify specific cultural ele- 
ments that might be operating in the observed clinical phenomenon. 
As researchers, this means adding specific cultural measures in 
studies. Doing so should decrease the adherence to indirect meas- 
ures of culture, as well as, post-hoc speculation about the role of cul- 
ture in psychopathology. For clinicians, this means conceptualizing 
the specific cultural factors that might be influencing the function- 
ing of a patient and directly testing for such factors. The more 
researchers and clinicians clearly define "what" about culture might 
be important and the more we directly assess the validity of cultural 
hypotheses, the better able we will be to accurately identify the role 
of culture in the psychopathology of Latinos. 



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s 



The Psychiatric Examination Across 
The Language Barrier 

Luis R. Marcos, M.D., M.Sc.D. 



At the beginning, all the earth had the same language and the same 
words. As men migrated from the East, they came upon the valley 
of Shinier and decided to build a city and a tower with its top unto 
heaven, to make a name for themselves. The Lord looked with con- 
cern at the city and tower which the men were building and said, 
"Let Me go down and confound their language, so that they shall 
not understand one another's speech" (Genesis, 11, 1-9). This is why 
the city was called Babel, because there the Lord confounded the 
speech of the whole earth. 

According to a report of the U.S. Bureau of the Census (1990), 
about 25 million persons speak a language other than English at 
home. Of this group, about 8 million do not speak English well, or 
do not speak it at all. The most common foreign language spoken 
at home is Spanish, which is used by over 14 million people, followed 
by Italian, German, French, Polish and Chinese. Today, the num- 
ber of limited-English and non-English-speaking persons in the 
United States is substantially higher due to the thousands of im- 
migrants and aliens who continuously enter and take residence in 
this country (U.S. Bureau of the Census, 1990). 

Although it is axiomatic that good verbal communication between 
clinician and patient is essential to proper psychiatric care, the num- 
ber of psychiatrists and other mental health professionals who can 
communicate in any of the foreign languages commonly spoken in 
the United States is very limited (American Psychiatry Association, 
1989). When a patient who is not fluent in English requires a psy- 
chiatric examination and no bilingual clinician is available, the usual 
practice is to conduct the evaluation in the English language and to 
use an interpreter only if the person is unable to communicate at all. 
In this paper, I will summarize the findings of a wide selection of cli- 
nical and research reports on the problems associated with employing 
English to assess the psychopathology of patients who have a limited 



1 30 Latino Mental Health 



command of this language. I will not address here the issues involved 
in the use of interpreters (Marcos, 1979a; Putsch, 1985). It should 
be noted that the largest portion of this literature reviewed has fo- 
cused on the Spanish-speaking population. 

A review of the literature on the evaluation of global psycho- 
pathology reveals lack of agreement as to whether the evaluation of 
limited-English speaking psychiatric patients in English raises or 
lowers clinician ratings of these patients' severity of illness. While 
there are reports indicating greater psychopathology in the primary 
language (Del Castillo, 1970; Gonzalez, 1978; Price & Cuellar, 1981; 
Ruiz, 1975), some studies show that Spanish-speaking psychiatric 
patients with limited proficiency in the English language are assessed 
as presenting higher levels of pathology when the language of inter- 
view is English rather than Spanish (Marcos et al., 1973a; Marcos 
et al., 1973b). Although it is difficult to compare these studies given 
their different populations and research designs, it is possible that 
these diverse findings may simply represent different snapshots of 
interactions among language, culture, clinical judgment, and psy- 
chopathology (Abad & Boyce, 1979; Lopez, 1988; Malgady, et al., 
1987; Rogler et al., 1989; Vasquez, 1982). At a more specific level 
of analysis, however, the literature reveals that several areas of the 
psychiatric examination are strongly influenced by the language bar- 
rier. These are the patient's general attitude toward the examiner and 
toward the interview situation, motor activity, speech, affect and 
emotional tone, and sense of self. Each of these will be examined 
in more detail below. 

General Attitude 

Patients struggling with a language barrier often behave in a self- 
effacing manner that clinicians may interpret as guarded behavior 
or uncooperativeness (Fitzpatrick & Gould, 1970; Kline, 1969; Sim- 
mons, 1961). These patients sometimes speak in ways that may create 
the impression of slow or reluctant participation in the interview. For 
example, in a comparative content analysis of the speech of primarily 
Spanish-speaking schizophrenic patients who were interviewed in 
both English and Spanish, a striking tendency was found for patients 
to answer English questions with just a word, a silent pause, or a 
short sentence such as "I don't know", "I don't think so", or "yes 
sir", all easily interpreted by clinicians as a reluctance to commu- 
nicate (Marcos et al., 1973a). Also, some foreign born immigrant 
patients whose English is limited may have a negative attitude toward 



Psychiatric Examination Across The Language Barrier 131 



the English language that can permeate their general predisposition 
toward the English-speaking clinician and the interview situation 
(Buxbaum, 1949; Edgerton & Karno, 1971; Horn, 1977; Marcos, 
1982; Rogler et al., 1980; Weinreich, 1953). 

In addition, because the language barrier interferes with the pa- 
tient's ability to understand the clinicians' verbalizations, particu- 
larly vocal cues such as intonation, pauses and emotional tone, the 
flow ofthe interview tends to be stilted and to lose emotional con- 
nectedness (Solomon & Ali, 1975). In turn, the demands placed upon 
the clinician to decide which of the patient's verbal cues are relevant 
and which are a mere consequence of his or her linguistic deficit, can 
cause interviewer frustration and uncertainty about the accuracy of 
the examination (Kline, 1969; Marcos, 1979c). Another factor that 
may affect the patient's attitude towards the interview situation is 
that some people, when communicating in a non-dominant lan- 
guage, tend to feel less intelligent, less friendly and less self-confident 
than they might feel if they were speaking in their primary language 
(Segalowitz, 1976). 

Motor Activity 

Clinicians view the quality and quantity of patients' body move- 
ments as a reflection of their affect (e.g., motor retardation and 
depression; enhanced physical tension and anxiety). In one study, 
Spanish-speaking schizophrenic patients, with a clear deficit in the 
English language, were rated by clinicians as more tense when in- 
terviewed in English than when interviewed in Spanish (Marcos et 
al., 1973a). A subsequent comparative analysis of their body move- 
ments showed that there was an actual increase in motor activity dur- 
ing the English interviews, but that the additional movements may 
have been associated with the more demanding task of encoding or 
verbalizing in the English language and not necessarily with psy- 
chopathology (Grand et al., 1977). Other experimental studies have 
confirmed that individuals produce more non-verbal activity, par- 
ticularly hand movements, when communicating in a language of 
which they have poor command. This may reflect either an increase 
in the work involved in verbalization or the patients extra effort to 
reach the interviewer and establish contact (Marcos, 1979 b). Clini- 
cians evaluating patients' motor activity in the face of a language 
barrier, therefore, confront the difficult task of separating ver- 
balization-related movements from those reflecting tension or anxi- 
ety (Freedman et al., 1972). 



132 Latino Mental Health 



Speech 

There is extensive clinical and experimental evidence demonstrat- 
ing that the speech of patients is affected in important ways when 
they speak in a non-dominant language (Diebold, 1967; Erwin & Os- 
good, 1954; Fishman & Cooper, 1971; Goggin & Wickens, 1971; 
Jakovits, 1961; Lambert, 1956; et al., 1956; Lambert, 1956; Maclay 
& Ware, 1961; Macnamara, 1967; Tanaka et al., 1963). For exam- 
ple, patients often verbalize primary language words during their En- 
glish language interviews. This "language mixing", or primary 
language intrusion, which occurs more often in answers to emotion- 
ally charged questions or in situations of higher stress, makes pa- 
tients' flow of thought sound less logical and more confused (Javier 
& Alpert, 1986; Javier & Marcos, 1989). Furthermore, patients strug- 
gling with a language barrier produce both longer silent pauses and 
more speech disturbances, such as incomplete sentences, self- 
corrections, repetitions, stuttering, and incoherent sounds (Marcos 
et al., 1973b). While these long pauses and speech disturbances have 
been considered to be indicators of depression and anxiety respec- 
tively in monolingual patients, they can also be a consequence of the 
patients' efforts to communicate in a non-dominant language (Al- 
pert et al., 1967; Mahl, 1959; Pope, 1965). 

Affect 

Many studies demonstrate that speaking in a non-dominant lan- 
guage diminishes the emotional involvement of the patient and may 
produce the impression of emotional withdrawal or detachment 
(Buxbaum, 1949; Krapt, 1955; Marcos, 1976; Stengel, 1939). This 
effect has been postulated as being due to secondary language words 
having less vivid associations, evoking weaker references, carrying 
less emotional charge, and being less meaningful emotionally 
stimulating than primary-language words (Gonzales-Reigosa, 1976; 
Javier, 1989; Marcos, 1976). If so, this may explain why limited 
English-speaking Hispanic schizophrenic patients often display more 
intense emotions when they are interviewed in the Spanish language 
(Del Castillo, 1970; Gonzales, 1978; Ruiz, 1975). 

There is also evidence that some patients, when speaking in a lan- 
guage in which they are less than fluent, focus their attention on the 
cognitive task of verbalization, and appear to concentrate primar- 
ily on the manner in which they say things and less on the content 
of what they are saying (Gonzales-Reigosa, 1976; Javier, 1989; 
Krapt, 1955; Sollee, 1970; Stengel, 1939). These patients may, for 



Psychiatric Examination Across The Language Barrier 133 



example, speak about emotionally charged material without display- 
ing the appropriate intensity of emotion. As a result, when com- 
municating in the non-dominant language, certain experiences can 
remain vague and unreal for both the patient and the interviewing 
clinician. Conversely, some clinical reports suggest that some bilin- 
gual patients may be able to reveal certain significant experiences in 
their secondary language which in the primary language were left un- 
told because of their high emotional content (Marcos & Alpert, 1976; 
Pitta, et al., 1978). 

Sense of Self 

Individuals communicating in a secondary language, as opposed 
to their mother tongue, not only have to deal with a different set of 
words but in some cases may perceive and describe themselves differ- 
ently, and experience a different sense of identity when speaking the 
non-dominant language (Marcos et al., 1977; Velikovsky, 1934). In 
fact, there are times when patients give different responses to the 
same questions in their primary and non-dominant language (Ervin, 
1964; Findling, 1969; Kolers, 1968). For instance, patients may 
report hallucinations only in their second language and deny hallu- 
cinations in their primary language (Hemphill, 1971), or they may 
describe different hallucinations, such as threatening voices in their 
non-dominant language, and "good" voices in their primary lan- 
guage (Frank, 1980; Lukianowicz, 1962). 

A classic yet still controversial explanation of these phenomena 
is the language-relativity hypothesis, which postulates that language 
is not merely a vehicle of communication, but it is a reality through 
which people perceive and organize their worlds (Fishman, 1960; 
Sapir, 1929). Alternatively, these findings may be associated with 
the bilinguals' capacity to acquire, maintain and use two separate 
language codes, each with its own lexical, syntactic, phonetic and 
ideational component (Diebold, 1967; Greenson, 1950; Lambert et 
al., 1956; Macnamara, 1967). Compelling evidence for the language 
independence in bilinguals can be found in many clinical and psy- 
cholinguistic studies (Ervin, 1964; Findling, 1969; Kolers, 1968). In 
addition, following cerebrovascular accidents, bilingual individuals 
often exhibit differential impairment of their two languages (Critch- 
ley, 1974; Marx, 1966; Paradis, 1977). 

Conclusions 

The psychiatric examination of limited-English-speaking patients 



1 34 Latino Mental Health 



places tremendous demands on clinicians who must face the difficult 
task of deciding which of the patient's verbal and non-verbal cues 
are relevant for the assessment of psychopathology, and which are 
"noise" or mere consequences of the language deficit that include 
the patient's attempt to overcome the language barrier. 

Ideally, clinicians should be able to communicate in the patient's 
primary language. As achievement of this state is unlikely in a na- 
tion as ethnically diverse as ours, it is essential that, at the very least, 
clinicians performing these evaluations be sensitive to the linguistic 
implications and attitudinal effects of the language barrier which can 
substantially influence the patient's general attitude, motor activity, 
speech, affect, and sense of self, as well as the clinicians' perception 
and interpretation of these. Potential misevaluation of the patient's 
responses may be minimized if the clinician is careful to anticipate 
the above referenced possible distorting effects. Beyond these edu- 
cational efforts, one must consider having trained interpreters readily 
available to intervene in situations where the low proficiency of pa- 
tients in the English language may substantially interfere with the 
accuracy of the examination. 



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9 



Hispanic Mental Health Research 
A Case For Cultural Psychiatry 

Horacio Fabrega, Jr., M.D. 



The purpose of this paper is to examine the mental health prob- 
lems of Hispanics from the standpoint of Cultural Psychiatry. This 
may be defined as the field of study that addresses relations between 
culture and psychiatric illness. In the present context, it involves 
analyzing the influence of Hispanic Culture on psychiatric illness 
problems of Hispanics: for example, the distribution, causes, mani- 
festations, diagnosis, course and treatment of such illness problems. 
These topics need to be examined in light of the fact that Hispanics 
comprise a large segment of a complexly stratified population of a 
pluralistic society. The way this society defines and handles psy- 
chiatric illness of Hispanics, viewed in relation to the way it defines 
and handles illnesses of other segments of the population, are topics 
that a cultural psychiatry should address. The mental health prob- 
lems of Hispanics and the way such problems are conceptualized 
and handled in a society, the dialectical interplay between illness 
phenomena and established categories of disorders, are integral 
to Cultural Psychiatry. Both sets of phenomena are seen as cul- 
tural in nature and as having political, economic and sociological 
consequences. 

In examining Hispanic mental health research it will be useful to 
introduce the idea of an Establishment Psychiatry. This constitutes 
the dominant professional perspective about mental health problems 
and is seen to reflect a universalist focus and a biological deter- 
minism. In Establishment Psychiatry, genetic and neurobiological 
structures are the real and important loci of psychiatric illness 
problems. The form of illness and distress that these structures give 
rise to are described as relatively fixed and common to homosapiens. 
This means that the nosology celebrated in the catechism of Estab- 
lishment Psychiatry, namely, DSM III R, is accurate, relatively un- 
problematic, capable of refinement and improvement as to the 
details but beyond the need of basic structural alteration. A model 



140 Latino Mental Health 



of psychiatric disorders is reflected in Establishment Psychiatry: un- 
derlying psychiatric disease processes surface as illness problems in 
their pristine natural form and are shunted to clinical research treat- 
ment establishments where they can be accurately identified, entered 
into suitable research protocols and eventually treated by means of 
the latest technologically refined practices that double blind studies 
have established are efficacious. It is instructive to examine how this 
"establishment" model of mental health problems conforms to real- 
ities as described for Hispanic populations. 

The Meaning of Hispanic Culture in 
Hispanic Mental Health Research 

We review in this section how researchers in the Hispanic men- 
tal health field appear to be using the concept of culture. One view 
seems to be that of a population trait, much like the standard demo- 
graphic variables of age, gender and social class (Lopez, 1989; Lu- 
bin et al., 1985; McLaughlin, Balch, 1980; Randolph et al., 1985). 
Hispanic culture is referenced by surname, place of birth or that of 
parents, physical characteristics, or simply by the subjects endorse- 
ment of "ethnic" preference. The role of culture in affecting such 
things as bias vis-a-vis diagnosis or treatment is all important and 
a researcher attempts to show statistical relationships between 
Hispanic identity and ways diagnoses are made and treatment mo- 
dalities structured. Important characteristics of Hispanics are either 
not addressed (simply the fact of differences versus a reference group 
is important); and if addressed, are often not spelled out ahead of 
time. The richness of the concept of culture and Hispanic culture in 
particular appears to be bleached out of these studies which rely 
merely on trait features of clients or clinicians. 

In studies of psychiatric epidemiology in Puerto Rico, (Canino et 
al., 1987; Helzer et al., 1990) culture appears to mean national iden- 
tity (refer to Helzer & Canino, 1989). Contemporary nations share 
a number of characteristics, such as political economic structures, 
social stratification systems, beliefs regarding science and secular ra- 
tionality and the desirability of Western education. There is power 
left in the concept of culture when differences are examined between 
Puerto Rico and St. Louis and especially Taiwan, but it is not clear 
that this is tapped in view of the rationale of these epidemiologic 
studies. As an example, much of the potential variability of cultural 
effects is weakened when purely quantitative aspects of drinking 
technologically processed forms of alcohol and when abstractly 



Hispan ic Men tal Health Research 1 4 1 



stipulated behavioral complications of heavy sustained drinking in 
modern societies operate as "effects" of culture and alcoholism. The 
studies by the Puerto Rico group are models of psychiatric epidemi- 
ologic research and rigorously attempt to examine cultural variation. 
Their work is based, however, on a pre-established model of alco- 
holism as a "disorder" and does not seek to understand cultural va- 
riations in the way alcohol is used, excess drinking conceptualized 
and handled and how all of this fits in with distress and impairment 
as culturally grounded. In short, that "alcoholism" must also 
be viewed in relation to Hispanic cultural traditions needs to be 
appreciated. 

The paper by Zippin and Hough (1985) more deeply considers cul- 
ture. They based their study on the alleged importance in Hispanics 
(Mexican and Mexican-Americans) of the family and significant 
others as natural support systems in the maintenanceof self function. 
The role of perceived difference between self and others with respect 
to life events was analyzed in relation to mental health. The authors 
predicted that Hispanics would be more affected by these differences 
than Anglos because of self-family integration differences stemming 
from cultural traditions. They found some support for their 
hypotheses. The report of this study is difficult to understand fully, 
and the study itself seemed to have problems. It constitutes, however, 
an example of one in which the content of Hispanic culture is more 
deeply made use of analytically. 

A much more elaborated use of the content of Hispanic culture 
is found in studies that concentrate on folk disorders and their mean- 
ings, either in rural or even urban populations. Some of these studies 
are descriptive and of course can entertain extended aspects of na- 
tive beliefs and theories (Rubel, 1960; Tousignant, 1984). Other 
researchers operate through more controlled data collection methods 
(Jenkins, 1988a and 1988b; Low, 1981, 1985). These studies are able 
to enhance one's appreciation of how culture affects responses and 
interpretations of psychiatric illness because of their empirically con- 
trolled methods, their focus on identified families of patients care- 
fully diagnosed, and the rich and sensitive use they make of cultural 
traditions. 

A more cautious approach is shown in the papers by Lopez and 
Hernandez (1986, 1987). They studied how mental health clinicians 
used the concept of culture in their work with clients. The authors 
analyzed case summaries provided by clinicians of cases in which 
they (the clinicians) judged culture had been used in diagnosis and 



142 Latino Mental Health 



treatment. In a somewhat reductionistic way, Lopez and Hernan- 
dez seem to struggle to uncover basic elements of culture that are 
used by clinicians in their attempts to diagnose and treat actual pa- 
tients identified because "cultural factors" loomed important. The 
restraint of the authors with respect to their claim that culture af- 
fects manifestations and nature of clinical psychopathology in 
Hispanics is notable and surprising. 

Differences in the way culture is used analytically reflect several 
things. The most obvious one is the kind of strategy and general 
orientation of the researcher. Empirically oriented, quantitative and 
quasi experimental studies require an abstract and static conceptua- 
lization of culture whereas ethnographic descriptive studies can 
luxuriate in symbols and semantic networks. And, of course, psy- 
chologists, social workers, sociologists and anthropologists have long 
traditions of research behind their efforts. Moreover, there are real 
philosophical problems in trying to "pin down" basic elements of 
culture, many seeing the attempt as flawed and missing the distinc- 
tion between explanation and interpretation. Finally, since Hispanic 
culture is invariably seen in relation to Anglo culture and both 
are integral to complex nation states, the quandary of cultural 
homogeneity versus pluralism is an issue as well. Factors such as 
these pose scientific dilemmas for the attempt to incorporate an un- 
derstanding of how cultural factors influence Hispanic mental health 
problems. Given the conventions that need to be followed in order 
to provide knowledge that will affect policy (e.g., what constitutes 
a disorder, how a cultural influence needs to be documented), quan- 
daries that make hard the full explication of cultural influences can 
be seen as retarding and/or blunting the efforts to promote a full 
appreciation of Hispanic mental health problems. 

One disappointment about the way the concept of culture is used 
involves the relative neglect of the specifics as versus varieties of 
Hispanic culture. In some respects Hispanics are handled as all alike, 
a factor that approximates how the concept of black ethnicity is used 
(Fabrega et al., 1989). There is a glossing over of the distinctness of 
the various regional traditions that contribute to "Hispanicity" (e.g., 
Caribbean as versus native Indian as versus Iberian) and sometimes 
of associated social variables (e.g., social class). Very often, the fact 
of Hispanicity is taken into account more deeply, but only with 
respect to degree of differentness or alleged "movement" toward 
the Anglo culture. A variety of scales of acculturation have been de- 
veloped for Mexican- Americans, Cubans and Puerto Ricans (Cuellar 



Hispanic Mental Health Research 143 



et al., 1980; Szapocznic & Kurtinez, 1980; Torrez-Matrullo, 1980) 
and this raises the question of what they might have in common and 
whether, in relation to mainstream Angloculture, the concept of a 
generic Hispanic culture has any power. It would be instructive to 
attempt to evaluate whether and, if so, how acculturation scales over- 
lap. Can different types of Hispanics (e.g., Mexican- Americans) be 
distinguished from others (e.g., Puerto Ricans) on these accultura- 
tion scales? What power is there, in fact, in the idea that there is a 
set of Hispanic cultural traits that transcend regional origins and so- 
cial class? These are questions intrinsic to a cultural psychiatric ap- 
proach. When answered in relation to mental health problems, they 
would clarify understanding of the way cultural factors impact on 
psychiatric illness and whether service providers and reimbursers 
accommodate or fail to accommodate to Hispanic realities. 

What is Hispanic Mental Health Research 
Doing and Where is it Going? 

Hispanic Beliefs, Attitudes, Illness Pictures and Systems of Care 

In an early study conducted in East Los Angeles, Karno and Edg- 
erton (1969, 1971) reported a general similarity among Anglo and 
Mexican-Americans regarding concepts of illness. In addition, they 
pointed to the importance of language orientation as relating to at- 
titudes and beliefs about psychiatric illness. Parra and Yiu-Cheong 
So (1983) conducted a study also involving attitudes and under- 
standings about mental illness among Mexican- Americans. This 
study was much less controlled than that of Karno and Edgerton. 
Parra found no support for an acculturation hypothesis and showed 
that younger Chicanos perceive mental illness differently and in a 
narrower way. In a report concentrating purely on attitudes towards 
the mentally ill, Parra (1985) showed that age and gender of the 
Mexican-American were influential but that in general few overall 
differences obtained between Anglos and Mexican-Americans. A 
classic topic of community centered study involves simply the 
description of folk illnesses among Hispanics. The studies of Rubel 
(1960) conducted in Mexican-American communities and those of 
Tousignant (1984) in Ecuador were already cited. 

The study of lay systems of care is a favorite topic in medical 
anthropology and health services research. Alegria et al. (1977) 
describes and analyzes some of the properties of the lay treatment 
centers available to Mexican- Americans of San Antonio. The study 



144 Latino Mental Health 



is conservative in posture, drawing attention to the separateness be- 
tween establishment as versus folk/lay systems of care. On the other 
hand, Kreisman (1975) reports on the creative integration of folk and 
establishment traditions in the treatment of two Hispanic psychotic 
patients. Hohman et al. (in press) have documented the extent to 
which spiritualism appears to be used as an adjunct support system 
in Puerto Rico. Building on insights of medical anthropologists (Gar- 
rison, 1977; Harwood, 1977), they relied on data gathered in an 
epidemiological study and showed that selected social characteris- 
tics, reported use of mental health professionals and subdiagnosable 
symptoms of depression were related in a logistic regression model 
with resort to spiritualists. Hohman et al. concluded that spiritualists 
did not appear to be major participants in the treatment of mental 
health problems in Puerto Rico. They point to the need for prospec- 
tive studies in order to better establish (1) when persons turn to 
spiritualists, and (2) the interplay between the resort to these lay as 
versus establishment "clinicians". The covert pattern of use of 
spiritualists in Puerto Rico versus Brazil, for example, is a factor that 
limits the validity and generalization ability of this study. The ex- 
tent of reliance of spiritualists is likely to be under-reported. 

Low (1981) showed the diverse components of the lay syndrome 
"nervios" in patients of medical and psychiatric clinics. The social 
cultural rootedness of perceived sources of nervios is underscored. 
She offers a cultural interpretation of this symptom complex showing 
that it signals family difficulties and a sense of personal dyscontrol 
but does not endanger a sense of social identity as does the concept 
of mental illness. In another paper, Low (1985) compares the ner- 
vios symptom complex in widely discrepant Hispanic and non- 
Hispanic settings arguing against the view that it constitutes a culture 
bound disorder. Jenkins (1988a) studied native conceptions and at- 
titudes about psychiatric illness among the relatives of Mexican- 
American schizophrenics. This study is insightful for the rich ana- 
lysis it provides of how the concept of nerves is used by family mem- 
bers to cope with the burden of psychiatric illness; and in particular, 
as a way of lessening stigma and maintaining solidarity. In a separate 
study, Jenkins (1988b) compares the difference in the way the con- 
cept of nerves is used by Anglos versus Mexican- Americans. This 
study constitutes something of a challenge to an important dictum 
of Establishment Psychiatry, that schizophrenic illness tends to be 
viewed similarly across cultures. Jenkins also discusses possible rea- 
sons for and functions served by the use of a concept of schizophre- 



Hispanic Mental Health Research 145 



nia versus nerves to explain disturbing symptoms involving cognition 
and emotion. 

These studies offer a Hispanic picture of the meaning of terms and 
concepts used by Establishment Psychiatry. For example, the con- 
cept of nerves is anchored deep in native Hispanic cultural traditions. 
Important questions are raised about establishment concepts and 
practices viewed as cultural versus biomedical phenomena. In other 
words, how Hispanic consumers view the material addressed by the 
establishment, how they are affected by its conceptualizations, and 
how they integrate native and establishment knowledge. 

The theoretical locus of these studies is far away from the setting 
where paradigms of Establishment Psychiatry operate. Hence, the 
information they produce does not directly challenge but simply sen- 
sitizes Establishment Psychiatry to alternative models. They warn 
that underneath and around the methodological tentacles that psy- 
chiatric epidemiologists thrust into the community, there exist a 
plethora of real-life mental health problems and ways of conceptu- 
alization and handling them that elude the epidemiologic reach. 
All of the latter problems mark the culturally authentic nature of 
psychiatric illness viewed in its cultural richness as versus biomedi- 
cal abstractness. 

Psychiatric Epidemiologic Studies Involving Hispanics 

Psychiatric epidemiology, generally speaking, is a field that is an- 
chored in establishment paradigms. Drawing on establishment con- 
cepts, it seeks to establish prevalence and incidence figures. Besides 
informing on these traditional measures, it can point to unusual clin- 
ically relevant facts and distribution patterns about a population. 
A number of such studies have raised awareness of distinctive clin- 
ical pictures and profiles of Hispanics. 

There is a long standing controversy involving the level of psycho- 
logical distress among Hispanics with much evidence suggesting 
mental health problems and some indicating artifacts produced by 
response style (Dohrenwend, 1966; Krause & Carr, 1978). Roberts 
(1980) has reviewed the literature pertaining to this problem and on 
the basis of a controlled study involving Mexican-Americans of 
Alameda County found support for increased distress as compared 
to Anglos. Many reports pointing to increased distress of Hispanics 
are a consequence of the scales used and the Hispanic's alleged ten- 
dency to somatize problems. Escobar (1987) and Escobar et al. 
(1987a, 1987b) have emphasized the high prevalence of somatization 



146 Latino Mental Health 



problems among Mexican- Americans. Angel and Guarnaccia (1989) 
have reported similar patterns among Puerto Ricans. Their study 
included a general explanation of the role of affective states, con- 
ceptions of self and social context in shaping psychological distress 
towards a somatization mode. It would appear that Hispanics, 
perhaps preferentially those of lower social class, express and show 
distress and maladaptation in a phenomenologically different mould 
than do the contrastive Anglo (i.e., white, non-Hispanic) group. 
Similar results involving somatization as an idiom for the expression 
of psychological distress of Hispanics have been found in Latin 
America (Escobar et al., 1983; Mezzich & Rabb, 1980). These studies 
all point to high levels of psychological and somatic distress in 
Hispanics and are to be distinguished from controlled psychiatric 
epidemiologic studies which aim to measure levels of disorders us- 
ing Establishment Psychiatry criteria and rationales. A somatization 
content to the Hispanic' s idiom of distress is tantalizing and com- 
pels interdisciplinary efforts aimed at clarifying the interplay between 
culture, emotion and the self. 

In studies aimed at measuring level of organic disorders, Escobar 
et al. (1986) have pointed out the fallacies of using the mini-mental 
status exam as a measure of organic impairment among Hispanics. 
They argue that language and educational level can contribute to 
spuriously high levels of cognitive impairment as measured by the 
Follstein battery. Bird et al. (1987) have produced comparable results 
in Puerto Rico. The study by Canino et al. (1987) of quintessential 
Establishment Psychiatry vintage, has underlined the similarity in 
epidemiologic profile with regard to selected psychiatric disorders 
between people of Puerto Rico and selected U.S.A. communities ex- 
cept for the former's higher measures of somatization and cognitive 
impairment (explained in large part like others mentioned earlier). 
The study by Garcia and Marks (1989) reports on the prevalence of 
depression among Mexican-Americans of Los Angeles using the 
CES-D scale. A higher level of endorsement of certain items of the 
CES-D was observed among Mexican-Americans versus Los Angeles 
non-Hispanic whites, but the meaning of this is not clear since mat- 
ters involving semantics and culture could be an explanation. The 
study raises the question, however, that depression may be realized 
differently in Hispanics versus Anglos and not just involving somati- 
zation. They also pointed to differences in the factor structure of 
depression symptoms among less adapted and younger Mexican- 
Americans. In a similar vein, Rubio-Stipec et al. (1989), using 



Hispanic Mental Health Research 147 



epidemiologic data from Puerto Rico, conducted factor analyses on 
the symptoms of the DIS that enter into the diagnosis of four types 
of disorders. They compared results with those obtained in the same 
way and using the same instrument for Mexican- Americans and An- 
glos of Los Angeles. They were able to show similar profiles for 
alcoholism and affective disorder but not phobic or psychotic dis- 
orders. Thus, even though the same parent set of symptoms and logic 
of evaluation were used, the symptom profiles of these latter two dis- 
orders failed to show concordance across ethnic groups. The results 
generally support the ideas of commonality and difference in the way 
symptoms cluster in Hispanics and Anglos. 

In an illuminating study using data collected by means of the DIS 
in Puerto Rico, Guarnaccia et al. (1989) have shown how the native 
syndrome "ataques de nervios" can elude the diagnostic reach of 
the epidemiologists. Many "somatic-anxiety" symptoms of this syn- 
drome happen to be picked up by the DIS and through an analyses 
of these, and from results of extra probes added to the study, they 
were able to show that probable ataque "patients" (compared to 
non-ataque "patients") were more likely to (1) receive certain DIS 
diagnoses (e.g., Depressive Disorder, Anxiety-Panic Disorders), and 
(2) use health care services (including spiritualists). Guarnaccia et 
al. (1989) suggest that ataques can be considered a cultural idiom 
of distress that describes a cluster of symptoms similar to panic at- 
tack but in contrast to the latter, it does not "come out of the blue" 
but follows culturally relevant social stresses. Their study thus raises 
questions about the cross-cultural validity of Panic Disorder as a 
nosologic syndrome, although it does tend to support the cross- 
cultural validity of key somatic symptoms of distress. Their study 
also raised questions about the cross-cultural validity of Somatiza- 
tion Disorder, many of the individuals receiving this diagnosis con- 
formed to the ataque mode of expressing distress but were diagnosed 
with a variety of other (serious) establishment diagnoses and ap- 
peared to be using somatization merely as an idiom. In general, 
Guarnaccia et al. (1989) have pointed to the problems created by the 
overlap between DIS/DSM III based disorders and the culturally 
sanctioned response "ataques de nervios". What passes as an accept- 
able idiom for distress in Puerto Rico (1) resembles and in some in- 
stances can conform to a DIS disorder; (2) can be correlated with 
certain DIS disorders; and (3) can modify and becloud the clinical 
picture of still others. A limitation of this study is that it tends to 
stop short of stipulating or at least commenting on whether and, if 



148 Latino Mental Health 



so, when a cultural idiom of distress constitutes an illness or medi- 
cal problem in the native Hispanic system and the differences be- 
tween such problems in the two systems of medicine (i.e., Hispanic 
and Establishment). 

In summary, studies of the type reviewed in this section can 
challenge Establishment Psychiatry but only weakly since they rest 
on its paradigms. They emphasize that establishment rubrics tend 
to constrain and shape the nature of the psychopathology it un- 
covers. Despite this bias, important differences in the structure and 
interpretation of symptoms among Hispanics are still manifest. In 
some instances, establishment categories appear to capture bona fide 
native mental health problems; in others, it inappropriately labels 
modes of communicating distress. As a result, the studies perpetu- 
ate the echo raised by community descriptive studies considered 
earlier regarding the cultural uniqueness of Hispanics vis-a-vis mental 
health pictures. An imperfect fit is obtained between Establishment 
and Hispanic models of mental health problems. Most importantly, 
the echo is sounded even when Establishment Psychiatry's instru- 
ments are used; its categories and its logic are used to compel atten- 
tion to cultural distinctiveness and to possible limitations of the 
establishment paradigms. 

Problems Inherent In the Way Hispanics are 

Diagnosed and Treated Using Establishment Conventions 

One of the strongest challenges to the way the establishment deals 
with the mental health problems of Hispanics is offered by those who 
concentrate on the dynamics of mental health care. This is a prob- 
ing challenge insofar as it makes clear how lacking in sensitivity are 
the diagnostic categories and the treatment practices of the es- 
tablishment. 

The papers by Del Castillo (1970) and Sabin (1975) are classic 
statements of the earnest concern of clinicians about the problem of 
underestimating psychopathology in Hispanic patients when the 
mother tongue is not used. On the other hand, studies by Marcos 
et al. (1973a, 1973b, and 1976) have disclosed that schizophrenics 
can actually appear more compromised and disturbed when inter- 
viewed in English. In contrast, the study by Lubin et al. (1985) re- 
ports that the picture of disability painted by bilingual subjects when 
they complete the depression adjective checklist is essentially the 
same regardless of whether they rely on Spanish or English; further- 
more, male bilinguals did not differ from females. Since this study 



Hispanic Mental Health Research 149 



did not identify who the subjects were (e.g., patients or non-patients; 
acculturated or non-acculturated), it is not possible to learn whether 
psychopathology per se is colored by language and/or culture; and 
since general descriptions of mood were employed, it is not possi- 
ble to specify whether significant aspects of illness problems that 
therapists must deal with are influenced by these same variables. 
Marcos (1976) has offered an analysis of the effects on and impli- 
cations for psychotherapy of relying on a patient's second language. 
McLaughlin and Balch (1980) found that ethnicity of clinician ap- 
peared to make little difference in the way clinical vignettes involv- 
ing Anglos and Chicanos were rated with respect to several clinical 
parameters. They, of course, relied on general hypothetical decisions 
involving idealized pictures of illness and did not probe in a realis- 
tic way either patient psychopathology or clinician practices. The 
study by Skilbeck et al (1984) documents that Hispanics seeking out- 
patient psychotherapy self report symptoms more prominently than 
blacks and that clinician's estimates of Hispanics' severity of disorder 
parallel the Hispanics' self reports. In this study, then, Hispanics 
were shown to differ from the way blacks self reportand were 
diagnosed, but Hispanics did not differ from whites. The study deals 
with a self selected group of individuals presumably sufficiently 
acculturated to seek establishment care and this may partially ac- 
count for their similarity to whites (Anglos). 

Review analyses and empirical studies (Lopez, 1989; Lopez & Mar- 
tinez, 1986, 1987; Lopez & Nunez, 1987) address the general problem 
of how cultural background affects diagnosis and treatment. Con- 
siderable emphasis is given to Hispanics, but other ethnic minori- 
ties are also included. The work by Lopez constitutes a sober and 
critical look at how Hispanics might fare badly as a result of possi- 
ble cultural biases inherent in establishment practices. Far from ac- 
cepting the popular dicta that culture affects psychopathology and 
invariably leads to biases, he is concerned to document empirically 
whether and if so how interview schedules and clinicians might deal 
with the potential problems of cultural differences. His papers can 
be consulted for details and analyses of findings of sources for bias. 
The study by Baskin et al. (1981) addressed Hispanics (and also 
blacks) and documented the association between ethnicity and 
psychiatric diagnosis and the influences of clinician ethnicity in all 
of this. 

Canino et al. (1987) showed that two Hispanic clinicians achieved 
acceptable reliability when offering multi-axial ratings of Puerto 



1 50 Latino Mental Health 



Rican children but they did not grapple with any notions pertain- 
ing to family and social class background that might influence a 
"cultural' ' orientation. In effect, this study emphasizes that estab- 
lishment criteria can be reliably applied to Puerto Rican children but 
leaves unexamined the questions of whether differences in cultural 
orientation might affect ease and/or relevance of diagnosis in terms 
of establishment paradigms. In other words, are there differences 
in the way disorders are manifest and/or in the applicability of di- 
agnostic categories among Puerto Rican children? Are all Puerto 
Rican children the same from a cultural standpoint simply because 
they live in the same island and speak Spanish or might there exist 
differences in beliefs, attitudes and behavioral styles that might af- 
fect the structure and content of psychopathology? Is the idea of 
modernization as versus traditionalism at all a viable one to apply 
to the cultural orientation of Puerto Rican children? What is dis- 
tinctly "Puerto Rican" and how does it vary in relation to social 
class? Or, could it be that the researchers are examining psy- 
chopathology in subjects before adult cultural differences become 
realized (i.e., enculturated)? (Refer to Shweder, 1985, for a review.). 
Finally, how might all of this differ among "mainland" Puerto 
Rican children? These questions can, of course, be applied to 
Hispanics from other nations. Besides touching on the topic of when 
or whether cultural differences become manifest, the questions raise 
the problem of cultural homogeneity versus cultural pluralism and 
the quandaries of measuring cultural orientation in a socially strati- 
fied society. 

Rogler and co-workers (Rogler, 1989; Rogler, Malgady & Costan- 
tino, 1987; iMalgady, Rogler &Costantino, 1987; Rogler, Malgady 
& Rodriguez, 1990) have underscored the ubiquity of the influence 
of culture in evaluation and treatment. They point to the vigilance 
that staff needs to adopt with respect to the implementation of es- 
tablishment concerns regarding care delivery and the beneficial con- 
sequences that can result from the rendering of services responsive 
to cultural identity. An interesting question, never directly formu- 
lated by them, is whether culturally sensitive services constitute 
Hispanic mental health care versus suitably modified Establishment 
Psychiatry care and/or whether any meaningful difference can be 
said to exist between these two posited categories. Olmedo's (1981) 
review deals with the question of testing linguistic minorities and 
points to the important influence of bilingualism, acculturation, and 
differences in explanatory framework. This review exclusively ad- 



Hispanic Mental Health Research 1 5 1 



dresses psychological assessment and is not central to issues of men- 
tal health per se. However, the controversy about I.Q. testing of 
minorities invokes the same reasoning as that involving the differ- 
ences between culturally authentic procedures as versus establishment 
procedures for assessing psychiatric disorders. 

Studies of the genre considered in this section are penetrating in- 
sofar as they point to insensitivities if not misguided efforts of relying 
narrowly on establishment methods, procedures and theories. 
Despite their critical and challenging nature, they are judged as 
limited to the extent that they do not force a true re-examination 
and/or reformulation of establishment rationales. The studies beg 
the following sorts of questions: Can or should a culturally sensi- 
tive approach to the problems of mental health of Hispanics rely on 
rationales developed using culturally distinctive epistemologies and 
paradigms? Should not establishment psychiatry paradigms be modi- 
fied or reformulated so as to authentically reflect the realities of 
Hispanics' mental health problems? 

Differences in the Way Psychiatric Disorders 
Are Realized in Hispanics. 

Studies which examine the symptom patterns of "bona fide" psy- 
chiatric disorders among Hispanics aim to document differences. 
Such findings may merely attempt to point to variability associated 
with ethnicity; however, because they can potentially uncover unique 
patterns of variability in Hispanics, they raise the question of the 
suitability of establishment conventions, if not stereotypes, with 
respect to specification of disorders. They thus pose a potential 
challenge to Establishment Psychiatry. Because the studies rely on 
abstract criteria for disorders, they tend to wash away cultural differ- 
ences. Thus, should such studies uncover differences they are seen 
as exposing more deeply embedded cultural biases (Fabrega, 1989). 

The study by Velasques and Gimenez (1987) dealt with three 
separate categories of psychiatric inpatients and was aimed at clarify- 
ing whether the MMPI could produce differences in symptom pat- 
terns that allowed distinctions based on diagnosis. The study adds 
to the literature that underscores the disparities between what the 
MMPI produces as compared to DSM III. Since the study did not 
rely on a protocol of evaluation that took culture into account in a 
significant way, it cannot be expected to weaken the claim that Es- 
tablishment Psychiatry categories as realized in the DSM III are in 
any way distorted or inappropriate. Furthermore, the fact that the 



1 52 Latino Mental Health 



study dealt with a highly special group of patients who were not cul- 
turally or linguistically specified (inpatients committed to a maxi- 
mum security facility) further limits what can be made of its results. 
The study by Randolph et al. (1985) compared the way Hispanic and 
Anglo schizophrenics reported symptoms. The rate of false positive 
diagnosis of schizophrenics based on the DIS was the same in both 
groups and no association between DIS diagnoses and ethnicity was 
found leading the investigators to judge in a preliminary way that 
the DIS was associated with little cultural bias. Furthermore, 
ethnicity was not associated with differences in DIS subscales or 
ratings based on other structured clinical instruments. Ethnic differ- 
ences resulted, however, in the way DIS negative subjects handled 
reports of illness in a face to face interview, with Hispanics consis- 
tently under reporting symptoms versus Anglos who in an open 
ended setting came forth with symptoms. In a subsequent report of 
the same study, Escobar et al. (1986) emphasized again the similarity 
between Anglo and Hispanic symptoms but indicated that Hispanics 
reported a later age of onset, more somatization and less time in 
hospitals. Since somatic symptoms are not criteria of schizophrenia 
in Establishment Psychiatry, the observed difference in clinical 
phenomenology of schizophrenia among Hispanics and Anglos is 
given little weight by the investigators. A limitation of the study is 
that it involved only Hispanic males who were relatively well accul- 
turated. In a study focusing on symptoms of depression and anxi- 
ety among Mexican- Americans of El Paso, Mirowski and Ross 
(1984) emphasized the importance of a belief in external control. 
They judged that Mexican culture through an emphasis on external 
control and fatalism produces opposed effects on anxiety as versus 
depression. Finally, the study by Rubio-Stipec et al. (1989) already 
reviewed above pointed to differences in the way Phobic and Psy- 
chotic Disorders were realized in Puerto Rico versus Anglos and even 
Mexican- Americans. On the other hand, concordance was shown 
with respect to Alcoholism and Affective Disorders. 

In summary, these studies all rely on establishment categories of 
disorder and establishment measures of psychopathology, and all 
seem to support the view that, within this version of psychiatry, 
Hispanics and Anglos in general present similar clinical pictures in 
some classes of disorders. The studies do not address the question 
of whether establishment rationales and formulations regarding the 
indicators of disorders might exclude, disregard, or simply be insen- 
sitive to aspects of psychopathology that may naturally inhere in be- 



Hispanic Mental Health Research 153 



havior patterns shaped by Hispanic cultural traditions. As indicated 
above, this was documented to be the case in Puerto Rico with 
respect to the symptoms associated with "ataques de nervios" (Guar- 
naccia et al., 1989) 

Research Involving Evaluation Instruments 

Given the awareness of the importance of language and culture 
in rendering mental health diagnosis and treatment sensitive to 
Hispanics, one can anticipate that a large effort has been mounted 
in the area of translation of instruments. If diagnosis of psychiatric 
illness were entirely an anatomical or physicochemical affair, this 
would be unnecessary, but given its behavioral basis and the depen- 
dence of accurate description on language, the emphasis on seman- 
tical and syntactical efforts becomes obvious. The study by Mahard 
(1988) involved assessing the value of the CES-D as a measure of 
depressive mood in an elderly Puerto Rican population. The alleged 
validity of this instrument was emphasized. Interviews were con- 
ducted in Spanish, but is not clear whether the instrument itself was 
either translated or completed by the interviewer as versus the pa- 
tient subject. 

The work of the Los Angeles and Puerto Rico group (Bravo et al., 
1987; Burnam et al., 1983; Canino et al., 1987) are examples of the 
effort to render establishment instruments suitable. The two Span- 
ish versions of the DIS that they have produced are in most respects 
identical in language although some modifications were introduced 
by the Puerto Rican group. In particular, they have (1) attempted 
to formally assess whether reports of unusual beliefs constituted psy- 
chopathology versus purely cultural perspectives (e.g., involving 
spirits) and (2) related reports of potential psychopathology to so- 
cial and psychological functioning. The problems of disentangling 
psychopathology from cultural material and establishing that reports 
of behavioral difficulties constitute true pathology have been 
squarely faced and resolved to the researchers satisfaction. Interest- 
ingly, the Puerto Rican group drew attention to the differences be- 
tween cultural conceptions and experiences of time in Los Angeles 
and their homeland. Most importantly, in a number of publications, 
the two groups of researchers have largely replicated profiles of relia- 
bility, validity and concordance of instruments and prevalence of dis- 
orders in mainland U.S.A. community settings. 

In reading these papers, one gets the impression that the 
researchers seem desirous of establishing commonality of methods 



154 Latino Mental Health 



of procedures by equating the "standardized" measures of the DIS 
obtained in non-Hispanics with those of Hispanics, and by obtain- 
ing epidemiologic measures that either match or not too strongly 
deviate from those obtained on the U.S. majority. In other words, 
the logic of DSM III which is the parental authority for the English 
and Spanish DIS, are handled as authoritative and non-problematic. 
Canino and co-workers (1987a, 1987b, 1987c) even assert that be- 
havioral problems well connected to native cultural traditions, such 
as those involving folk illnesses, are adequately captured by exist- 
ing categories in the catechism of DSM III. This perspective is con- 
sistent with that of most psychiatric epidemiologists and its cultural 
implications need to be appreciated; for example, an epidemiolo- 
gical study points to what Establishment Psychiatry deems is a bona 
fide psychiatric disorder. Its results stipulate the kinds of commu- 
nity mental health problems worthy of study and legitimately entitled 
to treatment. As implied earlier, discrepancies between establishment 
cultural categories of disorder and Hispanic cultural categories of 
illness (or "distress") constitute important raw data for a truly cul- 
tural analysis of how Anglo-American psychiatry operates in con- 
temporary society. 

Viewed in light of the science of psychiatric epidemiology, wor- 
kers involved in the translation of the DIS have performed a service 
to Hispanic mental health research by broadening the efficacy of a 
key assessment instrument. Problems in the validity of this instru- 
ment and in the community assessment of psychopathology remain, 
to be sure, but they are integral to establishment rationales and 
paradigms and cannot be covered here. 

Hispanic Research Involving Psychiatric Theory 

Research directed at the validity of diagnostic categories, at sys- 
tems of diagnosis, and at clinical facts regarding the cause, course 
and treatment of psychiatric disorders has the potential of question- 
ing basic structures of psychiatric knowledge. It is pertinent to ex- 
amine whether, and, if so, how mental health research involving 
Hispanics is contributing to this type of challenge of Establishment 
Psychiatry. The problem of genesis or precipitants of mental health 
problems will not be discussed since this has been amply covered in 
the literature. For example, the review analysis of Cervantes and Cas- 
tro (1985) involving the applicability to Mexican-Americans of a 
stress-mediation-outcome model can be consulted for an example 



Hispanic Mental Health Research 155 



of an attempt to examine the relevance of establishment etiology con- 
cepts for this group. The papers by Roberts (1987) and Ramirez 
(1987) are also germane. 

Alarcon (1983) has provided an eloquent critique of DSM III from 
the standpoint of Latin-American psychiatry. He draws attention 
to the need for psychocultural categories of behavior and culturally 
sensitive criteria of definition, in order to facilitate application of 
the basic rubrics of psychopathology. In a more specific sense, the 
bulk of his criticisms involve the questionable appropriateness of 
DSM III Axis II categories for Latin-Americans and the necessity 
of modifying Axes IV stressors and Axes V adaptive functioning so 
as to render them appropriate to the Latin American social setting. 
Mezzich (1989) has recently provided a general statement about the 
contributions that have and can be made to worldwide classification 
systems by researchers and clinicians knowledgeable of Latin- 
American psychiatric problems. His report lucidly outlines the pur- 
poses and rationale of classification in psychiatry and persuasively 
points to the need for taking into account Latin-American psy- 
chiatric realities. Alarcon (1983) and Mezzich (1989) both implicitly 
underscore the centrality of diagnosis and classification in constitut- 
ing a scientific psychiatry and they implore that such systems of 
codification should address the needs of diverse cultural groups. 
Their writings constitute an urging and exhortation to Hispanic men- 
tal health researchers; however, neither Mezzich nor Alarcon directly 
assert that establishment classification systems might be biased or 
that they might selectively ignore, over include or misrepresent 
Hispanic realities but this is certainly suggested. 

The studies conducted by the Los Angeles group (Jenkins et al., 
1986; Karno et al., 1987; Magana et al., 1986) on the course of 
schizophrenia, constitute another locus of scientific/academic ac- 
tivity that is centered on a critical pillar of Establishment Psychiatry. 
This study begins, much like other studies focused on Hispanics, in 
an attempt to replicate establishment "facts". In this instance, the 
role of expressed emotion among relatives of schizophrenic patients 
on the latter 's course of illness. Their results to date tend to support 
generalizations drawn from British and Anglo-American subjects. 
The relatively lower levels of EE among Hispanics versus Anglos was 
related to traditional notions pertaining to the family in Mexican cul- 
ture. The potential buffering effect of high contact families with 
respect to high EE among some relatives was hypothesized. In other 



156 Latino Mental Health 



words, high contact and high EE Hispanic family members may very 
well contribute stress to the patient but the high contact with low EE 
members that is available because of Hispanics larger families may 
ameliorate this effect. One anticipates that as these researchers tease 
out in a more elaborated but still controlled way the effects of family 
interaction in Hispanic families of schizophrenics, facts about the 
course of schizophrenia will come to reflect insights generated from 
the study of Hispanic culture in a compelling way. In this sense, es- 
tablishment facts could be seen as truly Hispanicized. 

The brief review of this section has posed questions with respect 
to what can be construed as an establishment fact about mental 
health research and practice, and what would constitute a Hispani- 
cized establishment fact in this knowledge paradigm? One can ex- 
tend this line of inquiry and rhetorically inquire as to what would 
constitute a fact in a truly Hispanic Psychiatry and additionally, 
whether and, if so, how much of a possibility there is for a univer- 
salistic establishment science of psychiatry that transcends cultures. 

The Political-Economic Implications of Hispanic 
Mental Health Research: A Focus for a 
Critical Medical Anthropology 

A theme within medical anthropology is focused on a critical ex- 
amination of theory and practice of biomedical psychiatry 
(Schepper-Hughes & Lock, 1986; Singer et al., 1990). In this light, 
it is instructive to examine in a general way the kinds of questions 
pertaining to Hispanic mental health research that a critical medi- 
cal anthropology could address. 

A requirement for a critical evaluation of how Hispanic mental 
health research fits into establishment psychiatric knowledge and 
policies would begin by first describing the size, distribution and so- 
cial composition of the Hispanic population, including its age, mar- 
ital structures, along with its religious, economic, educational and 
occupational profiles. The amount and kinds of mental health 
problems of Hispanics, those receiving and not receiving treatment, 
would need to be estimated. Levels of disorders as stipulated by es- 
tablishment criteria and levels of distress as realized in Hispanic 
populations would be needed. The social characteristics of disor- 
dered and distressed Hispanics need to be computed. This would be 
followed by a comparison of Hispanic parameters with those of 
other ethnic minorities; for example, that of Asians, Blacks, Ameri- 
can Indians and native Alaskans. 



Hispanic Mental Health Research 157 



How Hispanics in need of mental health care actually receive treat- 
ment is a problem that is not easy to establish. Community studies 
could provide estimates of the kinds of persons seen and institu- 
tions/clinics/hospital visited by Hispanics. A picture should ideally 
be developed of a putative Hispanic mental health system. The num- 
ber and types of Hispanic mental health practitioners, and their dis- 
tribution and mode of practice, would need to be collected and 
analyzed in relation to the size and characteristics of the population 
they service. Information pertaining to the social and ethnic com- 
position of the clients of Hispanic mental health workers and insti- 
tutions would need to be collected and analyzed to get a picture of 
who is being serviced in this "Hispanic mental health system." And, 
in areas where Hispanics constitute a sizeable population segment, 
the ethnic composition of the clients serviced by non-Hispanic mental 
health workers and institutions would also be needed. The languages 
spoken naturally by clients/patients versus service providers would 
need to be assessed. Finally, the picture that results would be com- 
pared to that painted about other ethnic/minority mental health 
workers and clients. 

The obvious aim of analyses such as these is to arrive at an over- 
all description of the mental health problems of Hispanics, how they 
currently receive mental health care and from whom, and the con- 
sequences of all of this. Thus, an estimate of the need for and ade- 
quacy of coverage of mental health services requires ascertainment 
of the quality of care received. This is an enormously difficult 
problem to clarify in the health services field generally. Ascertain- 
ing quality of care in the mental health field constitutes a no less 
formidable problem and ascertaining all of this in Hispanics, con- 
sidering the special and complex role that culture and language play 
in mental health care and social adaptation generally, can be ex- 
pected to complicate the problem even further. Nevertheless, such 
estimates and others that can easily be surmised are needed if one 
intends to examine Hispanic mental health problems in relation 
to how effectively Establishment Psychiatry is currently dealing 
with them. 

Despite the fact that one could conclude that establishment psy- 
chiatric science has been significantly broadened and sensitized by 
knowledge drawn from Hispanic mental health research (Rogler, et 
al., 1987, 1989), it is not at all clear that establishment psychiatric 
knowledge structures and practice directives have in fact accommo- 
dated to the need for services that this research underscores. How 



158 Latino Mental Health 



extensively and how well are Hispanic mental health needs being met, 
and how does this compare with the picture involving other minori- 
ties? Is a sufficient number of Hispanic mental health researchers 
and clinicians being produced in comparison to the size and need as- 
sociated with other ethnic, /minority groups? Is establishment psy- 
chiatric policy regarding the research and treatment of mental health 
problems sufficiently sensitive to cultural factors? Are administra- 
tors and funding agency representatives of Establishment Psychiatry 
adequately responding to the mental health needs of Hispanics; and 
how does this compare with policies, decisions, and subsidies affect- 
ing other ethnic/minority groups? 

The rationale for entertaining questions such as these arises due 
to such questions that are problematic and amenable to scientific in- 
quiry. A broad picture of cultural psychiatry takes into account the 
relationship between medical system characteristics (e.g., conceptu- 
alizations and theories of disorders) and community mental health 
problems as culturally and sociopsychologically contextualized. This 
relationship is studied across types of society. More directly, an im- 
portant concern is how the social and medical institutions of a so- 
ciety are describing, responding to and treating psychiatric illness 
problems, however these may be defined in the society. Cultural psy- 
chiatry is concerned with dialectics that involve such polarized en- 
tities as (1) biology and culture, (2) existing ''real world" psychiatric 
problems and conceptual paradigms about them, (3) knowledge of 
causes of disorder versus systems of practice, and (4) objectives of 
treatment and end products of treatment efforts. More directly to 
present concerns, a cultural psychiatry should address such dialec- 
tics as (1) assimilation and acculturation of cultural minorities to 
mainstream society, and (2) assimilation and acculturation of 
knowledge about minority mental health problems to mainstream 
or establishment psychiatric knowledge, practice and policy. 

The following are illustrations of questions that can serve to orient 
a culturally sensitive approach to Hispanic mental health research. 

1. Why should biologically validated "disorders" be the only 
analytic units in psychiatric epidemiology or assessment of need of 
mental health services? Do there exist indigenous syndromes of dis- 
ability that are not in the DSM III catalogue but should be? Should 
the formal requirements for the diagnosis of DSM III entities be 
modified to accommodate Hispanic realities? 

2. Is the complexity of a clinical condition of Hispanics (clinical 
condition equals the total clinical facts about a patient) greater than 



Hispan ic Men tal Health R e search 1 5 9 



that of Anglos? How easily are Hispanic disorders diagnosed? Does 
clinical complexity (e.g., pattern of co-morbidity, ease of diagno- 
sis, recourse to rule out diagnoses) differ in relation to degree of 
acculturation? Or, is there something intrinsic to the biocultural na- 
ture of Hispanicity that renders a clinical condition more or less com- 
plex in light of Establishment Psychiatry conventions? (Fabrega et 
al., 1989, 1990). 

3. Given the complexity of migration/acculturation experience 
with respect to social and psychological adjustment, is it possible to 
identify syndromes or disorders triggered by it that are not, but need 
to be included in a psychiatric nosology? Does the concept of an Ad- 
justment Disorder sufficiently account for migration/acculturation 
problems? If it does, should not Hispanic academicians be arguing 
for its legitimacy and authenticity as an entity in the nosology? 
(Fabrega & Mezzich, 1988). 

4. What correspondences can be drawn between mental health 
problems (including "bona fide" psychiatric disorders) realized in 
native Hispanics of Latin-America versus mental health problems 
of migrant Hispanics in the U.S.? Does resort to spiritual release 
through altered states of consciousness constitute a normalized pat- 
tern of behavior that promotes mental or physical health adjustment 
in Latin-American settings; and is the ease of resort to these ex- 
periences curtailed in the U.S.A., rendering migrants more vulnerable 
to mental and physical health problems? Is the community/society 
of the U.S. more secularized than that of Latin America? And if so, 
what losses or gains are accrued from a mental health standpoint as 
a result of migration? 

5. What benefits and/or deficits accrue to Hispanics who resort 
to indigenous healing traditions? Are there mental health problems 
for which indigenous healing traditions surpass establishment ones? 
Even if establishment mental health services are rendered culturally 
sensitive, can a valid and useful calculus be created for measuring 
the benefits and losses incurred to a hypothetical Hispanic patient 
as a result of receiving such services with reference to specific psy- 
chiatric disorders? Is the loss associated with establishment treatment 
of a particular disorder greater or smaller than that associated with 
indigenous treatment? What parameters of a disorder compel estab- 
lishment treatment versus indigenous treatment? 

6. A psychiatric diagnostic system should inform a mental health 
clinician about something of clinical value for understanding and 
managing a patient's condition. Could one develop an axis that takes 



160 Latino Mental Health 



into account the ability of a Hispanic person to constructively make 
use of psychiatric treatment and profit from it? This might include 
such things as (1) reading, speaking, writing skills in English; (2) 
awareness and acceptance of establishment models of psychiatric ill- 
ness and treatment; and (3) level of stigma accorded psychiatric ill- 
ness by persons and significant others? Alternatively, the capacity 
of a person to integrate within and participate in mainstream soci- 
ety could be assessed and measured. This might include such things 
as level of educational attainment, acquired working skills and 
habits, level of social skills, availability of support groups and degree 
of opportunities and/or ambitions for assimilating into mainstream 
society. It is obvious that the phenomena considered in this axis of 
a psychiatric diagnostic system blends with phenomena subsumed 
by the concepts of assimilation and acculturation. Hispanic mental 
health researchers, with other ethnic minority groups, could usefully 
be engaged in developing such an axis to render the catechism of 
Establishment Psychiatry (i.e., DSM III R) truly responsive to 
Hispanic needs. 

7. What would constitute a valid psychiatric treatment outcome 
measure for Hispanics? What areas of behavior as formulated in 
terms of Hispanic traditions constitute a return of function among 
Hispanics? Are the rationales and instruments used in the field of 
psychiatric rehabilitation sensitive to behavior and adaptation modes 
of the Hispanics? 

Hispanic Mental Health Research Knowledge 
Viewed From the Standpoint of Social 
Change and Cultural Evolution 

Hispanic Americans constitute a relatively large minority of the 
population. Consequently, their mental health problems are not an 
inconsiderable part of what the science and practice of Establishment 
Psychiatry should address. Moreover, because it is a large minority 
and growing, their problems of mental health when properly defined 
and understood should, in theory, play a role in contributing to the 
production of Establishment Psychiatric knowledge itself. Further- 
more, because Hispanic Americans and their native language and 
culture are linked directly to that of a large portion of the popula- 
tions in the Western Hemisphere, and Iberian peninsula on the 
European continent, Hispanicity constitutes an important influence 
in molding the social and psychological behavior of a large segment 
of the world population. In other words, even though one must con- 



Hispanic Mental Health Research 161 



cede great variability, it is still the case that Hispanic cultural tra- 
ditions involving conceptions of self and other, styles of emotional 
experience and expression, patterns of social relations and general 
attitudes and values about life, to name but a few, are social psy- 
chological parameters that share basic structures and content among 
a large number of people of the world. To the extent that aspects of 
mental health problems reflect these and related cultural themes, one 
must assume that cultural parameters of a Hispanic psychopatho- 
logy are important elements that the theory and practice of a truly 
representative psychiatry should address. And finally, the premises 
and knowledge structures of any truly representative psychiatric 
science should ideally reflect insights about psychiatric illness borne 
out of the study of the mental health problems that are found in 
Hispanic subjects. 

The preceding constitutes a general rationale for the incorporation 
of research knowledge about Hispanic mental health problems in a 
representative science of psychiatry. To look critically at how Esta- 
blishment Psychiatry operates in relation to Hispanics (or Blacks, 
Asians, Native Americans and Eskimos) is to adopt a cultural 
psychiatric and historical/evolutionary approach. This is the case 
because in this approach the concepts of culture and that of societal/ 
historical change are all important. They are used (1) to make sense 
of what constitutes a Hispanic psychiatric illness (i.e., what con- 
sumers of mental health services need and want); (2) to understand 
what service systems controlled by Establishment Psychiatry are able 
and willing to offer and why; (3) to enumerate the discrepancies and 
inconsistencies regarding definition of problems and structures of 
care; and (4) to describe the processes of social and historical change 
that are set in motion when these differences are made public 
through research. All of this is seen as integral to political economic 
factors operating in the society and on Establishment Psychiatry and 
to sociological factors promoting historical change. 

Researchers who are interested in the problems of cultural evo- 
lution, as well as problems of acculturation/assimilation viewed in 
a historical framework, have a test case in the field of ethnic minority 
mental health research. The impetus for and the nature and con- 
sequences of ethnic minority research reflects the process of ac- 
culturation/assimilation viewed in a cultural evolutionary frame of 
reference. Ethnic minority research may be conceptualized as a com- 
ponent of the adaptive response of the ethnic minority group itself. 
Viewed generically, an ethnic minority group encounters adaptive 



162 Latino Mental Health 



problems and challenges in the parent society and responds with a 
mixture of negative and positive adaptive changes. Research involv- 
ing the mental health problems of the ethnic minority group is one 
such potentially positive response since it is often produced by 
minority/ethnic researchers, is prompted by deficiencies or puzzles 
found in the established mental health practice and knowledge struc- 
ture of the society and is at least partially geared to changing, 
modifying or sensitizing them. Ethnic minority groups differ with 
respect to how actively they become involved in producing research 
knowledge about the social conditions (and otherwise) that contrib- 
ute to mental health problems. The Hispanic group's social condi- 
tions, mental health problems, and adaptive research responses must 
be assumed to be different from that of Blacks, Asians and Native 
Americans/Indians. In short, if one adopts a large scale cultural 
evolutionary view of minority mental health research, a number of 
interesting questions may begin to be formulated. 

1 . What is the relationship between the social characteristics of 
the ethnic minority population and the kinds of mental health 
research questions it generates, is able to solve and, in fact, attempts 
to solve? How does all of this contribute to the plight of the ethnic 
minority group? Are there differences across ethnic minorities and 
how is one to explain these differences? 

2. In a proximal sense, what promotes minority research? Is it to 
be viewed as an affirmation of the minority's "spirit" stemming 
from policy requirements of administrative agencies and personnel, 
or is it simply a result of interests posed by the problem itself, a 
purely cognitive scientific matter involving curiosity? 

3. How do the cultural, historical and political economic condi- 
tions of an ethnic group contribute to its social adaptation in the 
larger, "parent" society and are the distinctive mental health 
problems that result properly represented in research? What are the 
generic conditions that attend the adaptation of ethnic groups versus 
the culturally distinctive ones? What are the mental health correlates 
of these two types of conditions and which ones are favored by 
researchers and policy setting representatives of funding agencies? 
How are the results of research on ethnic minority groups used in 
the parent society? Do the insights and knowledge structures 
produced by ethnic minority researchers make an impact on adminis- 
trators such that the social conditions and associated mental health 
problems are adequately studied, modified or confronted differ- 
ently? How do these factors differ across ethnic groups and why? 



Hispanic Mental Health Research 163 



4. To what extent is ethnic minority mental heath research a 
spearhead for social and political change? To want extent does it 
merely follow or reflect social and political changes taking place in 
the society at large? 

Summary and Conclusions 

Some of the research literature pertaining to mental health 
problems of Hispanics was reviewed. An underlying emphasis of the 
essay is that contemporary mainstream perspectives on mental health 
problems are governed by definitions, rationales and imperatives that 
are positivistic and strongly influenced by biological factors. The 
dominant perspective was termed Establishment Psychiatry, because 
knowledge and practice conventions are integral to professional col- 
leges and universities, research institutes, research funding agencies, 
public as well as private institutions that pay for mental health ser- 
vices, and the fact that the underlying theory behind these directives 
is certified by the state. In effect, social policy regarding mental 
health research and services provision is set by Establishment Psy- 
chiatry. Research involving mental health problems of Hispanics was 
examined in terms of how it relates to Establishment Psychiatry. In 
general, the research broadens the knowledge base of Establishment 
Psychiatry. Psychiatric epidemiologic knowledge in particular has 
been extended to cover Hispanic populations, and the study of the 
course of schizophrenia has been sharpened and deepened through 
work involving Mexican- Americans. Much research has pointed to 
biases in diagnosis and to differences between establishment 
paradigms of disorders and Hispanic models of psychiatric illness 
and distress. Although some have suggested that Hispanic cultural 
realities in the area of psychiatric illness need to be included in es- 
tablishment conventions, few have actually challenged the validity 
of such conventions in a direct way. The paper implicitly and ex- 
plicitly attempts to point out how Hispanic realities might be used 
to render Establishment Psychiatric conventions more representa- 
tive and valid. Hispanic mental health research knowledge is also 
examined from the standpoint of political economic factors and 
the change and evolution that inevitably affects social and medical 
systems. 



164 Latino Mental Health 



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Tousignant, M. (1984). Pena in the Ecuadorian Sierra: A psychoanthro- 
pological analysis of sadness. Culture, Medicine and Psychiatry, 8, 
381-398. 

Velasquez, R.J. and Gimenez, L. (1987). MMPI differences among three 
diagnostic groups of Mexican- American state hospital patients. Psycho- 
logical Reports, 60, 1071-1074. 

Zippin, D.H. and Hough, R.L. (1985). Perceived self-other differences in 
life events and mental health among Mexicans and Americans. Journal 
of Psychology, 149, 143-155. 



io 



DSM-IV Development and Hispanic Issues 

Juan E. Mezzich, M.D., Ph.D. and 
Javier Saavedra, M.D. 



As a nosological introduction to the topic at hand, this paper will 
examine first the structure of a standard diagnostic system, followed 
by a review of the principles being used for the development of DSM- 
IV. Next, Hispanic issues pertinent to diagnosis and assessment will 
be considered. Finally, perspectives for enhancing the cultural sen- 
sitivity of the DSM-IV diagnostic system will be analyzed. Particu- 
lar attention will be paid to special syndromes, diagnostic criteria, 
qualifications in the text and multiaxial formulation. 

Key Structural Aspects of a Standard Diagnostic System 

Diagnostic systems constitute attempts to represent reality in a way 
that could be helpful to understand clinical cases and to act in profes- 
sionally effective ways. The diagnostic model is supposed to be a 
summarized approach employed to assist in the retrieval of infor- 
mation and to serve the various purposes of diagnosis, such as 
facilitating professional communication, making treatment deci- 
sions, planning public policies, conducting etiological research and 
enhancing theoretical understanding (Mezzich, 1989a). 

Descriptive psychopathology developed during the first half of 
the 19th century in France (Berrios, 1984). At present, as we know, 
description of psychiatric disorders are heavily based on symptoms. 
Within such a framework, flexibility can be used to represent real- 
ity in a way that is helpful and useful. Most importantly, a diagnostic 
system should attempt to reflect the patient's condition as faithfully 
as possible. Type of psychopathological description is crucial to the 
identification of a case. It is important, however, to go beyond the 
traditional ways of describing psychiatric cases and not limiting our 
concept of diagnosis to just a list of categories. 

In order to identify critical points and levels of a diagnostic sys- 
tem, two aspects of its architecture must be considered: first, the 
taxonomy of mental disorders and the principles that vertebrate 



1 72 Latino Mental Health 



such classification, and second, how to organize a full diagnostic 
formulation. 

Taxonomy of Mental Disorders 

Stengel (1959) noted in his review of classification systems used 
in various parts of the world that etiology and phenomenology have 
traditionally been used in various combinations to articulate most 
psychiatric classifications. At present, the emphasis is on descrip- 
tive psychopathology. Currently, there is interest in making the clas- 
sification as minimally inferential as possible. Accordingly, higher 
orders concepts such as psychosis and neurosis are given less impor- 
tance. With respect to etiological elements, although clearly present 
in areas such as organic mental disorders and adjustment disorders, 
they do not have an over-arching role in the organization of recent 
classifications. 

Psychiatric classifications have some form of hierarchical organi- 
zation. There are major classes of psychiatric disorders and types 
and subtypes within each of them. In ICD-10, an attempt has been 
made to organize each chapter (e.g., infectious, circulatory or mental 
disorders), in such a way to arrange these catalogs into clusters. In 
this regard, it can be helpful, not only to understand the map of psy- 
chopathology, but also the formulation used in reporting it. It would 
be desirable for the top levels of a diagnostic hierarchy to be as 
meaningful and informative as possible. This is particularly com- 
pelling when there are logistical limitations in data gathering, re- 
porting and analysis, as it often happens in developing countries 
(Mezzich, 1989a). 

Another important point, besides the specificity of diagnostic 
categories needed for definitional clarity, is the role of residual, non- 
specific categories. Besides their practical usefulness in preliminary 
evaluations, they allow flexibility for incorporating the classifica- 
tion syndromes not previously listed, as well as those of local or 
regional importance. 

Of special interest are the different ways of categorizing diagnostic 
entities, including the classical model which assumes homogeneous 
diagnostic groups with distinct boundaries and defined by singly 
necessary and jointly sufficient features. On the other hand, the pro- 
totypic approach assumes heterogenous group membership, fuzzy 
and overlapping boundaries, and descriptive features that are cor- 
related with, but not required for, group membership (Cantor et al., 
1980). The former model can be considered deterministic and the lat- 



DSM-IV Development and Hispanic Issues 1 73 



ter probabilistic. There is an evolving consensus that, at least for 
problematic disorders blending with normality, prototypic ap- 
proaches are most reasonable. In DSM-III there was an intent to be 
prototypic in the definition of some personality disorders and in 
ICD-10 this approach goes further, as indicated by the definition of 
all personality disorders with the same number of diagnostic criteria. 
Another critical issue in the definition of mental disorders involves 
inclusion and exclusion criteria. DSM-III-R is characteristically more 
relaxed in the use of exclusionary factors than DSM-III, and, there- 
fore, it allows a larger number of diagnoses to be formulated (Fen- 
ton et al., 1988; Gift, 1998). This has made more conspicuous the 
issue of comorbidity in clinical populations. 

Organization of a Diagnostic Formulation 

In considering the structure of diagnostic systems, a crucial con- 
trast is that between the single label and the more complex formu- 
lations for the patient's condition. This dilemma usually takes the 
form of uniaxial versus multiaxial approaches. The former tries to 
summarize a case with just one category, in what is purported to be 
the "Kraepelinian Approach." Even Kraepelin, however, in his more 
mature years, acknowledged statistical mistakes in early analyses on 
courses of illness and acknowledged that non-disease-entity aspects, 
such as personality, significantly influence the course of "demen- 
tia praecox" (schizophrenia). 

According to the multiaxial approach, in addition to the descrip- 
tion of psychopathology, there are a number of biological and psy- 
chosocial factors that seem to be important for an effective portrayal 
of the patient's condition. It represents a more analytical, and at the 
same time, a more comprehensive approach. The use of this ap- 
proach also offers the opportunity for flexibility in scaling, as dimen- 
sional ratings are often employed in addition to the more traditional 
categorical judgments (Mezzich, 1985). The latter has its roots in 
what has been, since the dawn of mankind, a human survival skill 
(Raven, Berlin & Breedlove, 1971). 

An international consultation on multiaxial diagnosis sponsored 
by the World Psychiatric Association (Mezzich, Fabrega & Mezzich, 
1985) found that five was the largest number of axes that a majority 
of 175 expert diagnosticians responding from 52 countries considered 
feasible for regular patient care. Worth mentioning is the work of 
Efren Ramirez (personal communication), in the Mental Health 
Services Office of Puerto Rico, using an octaxial diagnostic approach 






1 74 Latino Mental Health 



that is quite commendable in trying to use eight axes, which include 
psycho-religious and other adaptive functioning aspects perceived 
as critical for the evaluation of patients in that part of the world. Five 
of the aspects, or perspectives, most frequently considered in psy- 
chiatric multiaxial diagnostic systems are as follows: general psy- 
chiatric syndromes, stable behavioral handicaps, general medical 
disorders, environmental context, and disabilities. 

Development of DSM-IV 

The project of developing the fourth revision of the DSM began 
shortly after the publication of DSM-III-R, notwithstanding con- 
cerns about the pertinence of its elaboration (Zimmerman, 1988). 
The DSM-IV Task Force appointed by the American Psychiatric As- 
sociation pointedly considered ICD-10 in its deliberations, not only 
because of the agreement by the United States and most other coun- 
tries to use the WHO's reference instrument, but also because ICD- 
10 is quite innovative and advanced vis-a-vis ICD-9 and previous 
versions (Frances et al., 1989). 

There were three stages or basic elements in the development of 
DSM-IV. One was the review of the literature on DSM-III and DSM- 
III-R. The second involved re-analyses of available data sets. The 
third included field trials of proposals advanced for DSM-IV 
(Frances et al., 1990). 

First, reviews of the literature on experience obtained with DSM- 
III and DSM-III-R were conducted in the systematic way usually 
associated with empirical research projects. This included a clear for- 
mulation of the nosologic problem to be investigated, the computer- 
ized and manual methods used to identify relevant literature reports, 
the tabulation of findings to facilitate the elucidation of patterns, 
and the thoughtful formulation of conclusions, options and recom- 
mendations. These reports are published in the Source Book that 
accompanies DSM-IV. 

Second, re-analyses of available data sets were aimed at clarify- 
ing those nosological questions which remain outstanding, after the 
literature reviews have been completed. They tend to use multisite 
designs and comparative approaches. For the most part, these re- 
analyses were being funded by the MacArthur Foundation. 

The third investigational stage in the development of DSM-IV in- 
volved conducting field trials in a number of different areas, such 
as: antisocial personality disorder, autism, conduct disorder, 
schizophrenia, mood disorders and anxiety disorders. The National 
Institute of Mental Health funded most of these field trials. 



DSM-IV Developmen t and Hispanic Issues 175 



Also of interest in the process of developing DSM-IV were efforts 
addressed to enhancing its cultural validity (Mezzich, Fabrega & 
Kleinman, 1992). The development of DSM-IV represented an op- 
portunity to deal more effectively with the challenges posed by 
Hispanic and other ethnic-identified populations. 

Latin American Contributions and Issues 

In considering Hispanic issues pertinent to classification and di- 
agnosis, it is useful to review first some Ibero-American contribu- 
tions, in order to identify themes and emphases that represent Latin 
concerns, followed by mentioning Hispanic issues relevant to diag- 
nosis. With respect to diagnosis and classification, Horwitz & Mar- 
coni (1966) in Chile made an articulate plea for diagnostic definitions 
to be formulated in objective and operational terms. Leme-Lopes 
(1954) from Brazil pioneered the development of specific multiaxial 
systems. Leon (1970) conducted a pioneering survey of the attitudes 
of Latin-American psychiatrists toward existing diagnostic systems 

With regard to the original description of regional syndromes 
(such as susto and dano), folklore, and cross-regional contrasts, the 
works of Seguin (1946), Bustamente (1961) and Perales (1985) are 
of pioneering value. Also, the descriptions of syndromes induced by 
local drugs of abuse such as cocaine and its pasta basica opened new 
paths in the field (Jeri, 1978; Nizama, 1979). In relation to the con- 
ceptualization of illness, Seguin (1946) emphasized the role of stress; 
Fabrega (1975) pointed out the necessity for a ethno-medical ap- 
proach to illness; and Mariategue (1985) formulated the development 
of alcoholism in a penetrating, historical and ethnographic way. 

Critical Hispanic Issues 

Ibero-American issues identified across the Americas are pertinent 
here. Cuellar (1982), in analyzing the various phases of the diagnostic 
process where sociocultural factors may play a role, concluded that 
failure to consider the whole patient, including cultural background, 
could substantially confuse diagnosis and treatment. Cuellar and 
Roberts (1984) found that cultural influences on form and content 
of symptoms are critical. Reflecting on the suitability of DSM-III 
for Latin- American populations, Alarcon (1983) pointed out the 
limited transcultural appropriateness of its diagnostic criteria for 
several components, particularly personality disorders. Santisteban 
and Szapocznik (1982) cogently argued for a bicultural approach to 
understand acculturation and the development of substance abuse 
among Hispanics in the United States. Alarcon (1983) and Seguin 



176 Latino Mental Health 



(1946) called attention to the presence in Latin- American popula- 
tions of intriguing regional and local syndromes. Furthermore, as 
Fabrega (1988) has noted, much of what is included in standard di- 
agnostic systems are indeed culture-bound syndromes, but, in this 
case, bound to Western culture. 

Sociocultural stressors are highly relevant to Hispanic mental 
health and illness. Parron (1982) has described specific stressors for 
ethnically identified minorities in the United States, such as 
prejudice, discrimination, and cultural-linguistic barriers. Becerra 
et al. (1982) pointed out the significant vulnerability of Hispanics 
as a group to the stress of acculturation and migration. In regard to 
support systems, Alvarado (1985) in South America found empiri- 
cally, not only that a low level of support systems appears to increase 
vulnerability to adjustment disorders, but that the quality of the sup- 
ports tends to improve the outcome of such disorders. In the United 
States, while family networks among Latin- Americans represent a 
frequent source of considerable support, there are limitations in the 
access of this ethnic group to the resources of the community at large 
(Escober & Randolph, 1982). 

Another important diagnostic issue is language. Spanish (as well 
as Portuguese) is a fundamental aspect of Latin-American culture 
(Parron, 1982) and must be seriously considered in relation to both 
the expression of psychopathological experiences and the profes- 
sional interpretation of such experiences. 

Perspectives for Enhancing the DSM-IV Diagnostic System 

In order to enhance the cultural validity of standard diagnostic 
systems, it is critical to identify and work on propitious elements and 
aspects of the diagnostic system structure. In this regard, we shall 
consider the opportunities offered by the introduction to the diag- 
nostic manual, such as inclusion of new diagnostic categories, ad- 
justment of diagnostic definitions, design of multiaxial systems, and 
development of a complementary cultural formulation. 

Scholarly and empirical research on psychopathology must be in- 
formed by culturally relevant models. Rogler (1989) argues that 
research is made culturally sensitive through a continuing incessant, 
and open-ended series of substantive and methodological insertions 
and adaptations designed to mesh the process of inquiry with the cul- 
tural characteristics of the group being studied. Furthermore, the use 
of adequate diagnostic tools to gather multi-perspective data is cru- 
cial (Cuellar & Roberts, 1984; Mezzich & Berganza, 1984). 



DSM-IV Development and Hispanic Issues 1 77 



Introduction to the Manual 

This represents an opportunity to guide clinicians and researchers 
on how to use the whole diagnostic manual and how to conduct a 
diagnostic evaluation in a culturally sensitive manner. Proposals here 
present the rationale for considerations that include evolving demo- 
graphics and international issues. Cultural recommendations are 
highlighted, particularly for problematic areas such as personality 
disorders. 

Inclusion of New Diagnostic Categories 

One way to recognize diverse cultural realities in a diagnostic sys- 
tem is to incorporate syndromic categories observable in sizeable seg- 
ments of the population. Categories such as Neurasthenia and 
Trance, and Possession Disorder, were proposed for inclusion in 
DSM-IV. This could be implemented by using standard diagnostic 
codes (somatoform or dissociative disorders) as fully distinctive 
categories, or housed under "other" or "unspecified" categories 
within pertinent sections of the catalog of mental disorders. Alter- 
natively, in subsequent editions such proposals could be accom- 
modated in the Appendix of the DSM-IV Manual and listed as 
categories requiring further research. Culturally bound syndromes 
and issues could be included as a glossary in the Appendix of the 
DSM-IV Manual. These syndromes could be cross-referenced, when 
appropriate, with corresponding to standard diagnostic categories. 

Adjustment of Diagnostic Definitions and Cultural 
Considerations in Associated Text 

Diagnostic definitions should be adjusted to recognize important 
cultural variations, particularly at the level of diagnostic criteria for 
categories highly dependent on cultural norms. In a more circum- 
spect way, flexible adjustments are suggested in the form of cultural 
considerations printed in the text associated to the diagnostic 
categories in question. Optimally, considerations will have a format 
similar to recommendations for age and gender variations. An ex- 
ample are somatic symptoms as conspicuous in the characterization 
of depressive disorders in Latin American populations (Mezzich & 
Raab, 1983; Escobar et al., 1983). 

Development of a Multiaxial Schema 

The development of a multi-axial schema for DSM-IV offers a po- 
tent opportunity for the consideration of relevant cultural issues. All 



178 Latino Mental Health 



axes, including those on mental and general medical disorders, are 
in need of cultural enhancement. Particularly important is work con- 
nected to the axes on environmental psychosocial factors (stressors 
and support systems) and on adaptive functioning. Among the 
former, one must consider barriers to mental health care, such as 
language, geographical distribution and socio-economic problems, 
as well as importance of the family as source of support among 
Latinos. Regarding functioning, cultural norms such as a coopera- 
tion versus competition need to be considered. 

Complementary Cultural Formulation 

Mezzich and Good (1991) developed a proposal to supplement the 
nomographic ratings of standard diagnostic systems with key ideo- 
graphic points. Such points cover the personal experience of the 
patient, understood within a pertinent cultural context, and the struc- 
ture and dynamics of the patient/doctor relationship. 

The aforementioned recommendations were formulated for the 
cultural enhancement of DSM-IV. They were actively worked out 
by a scholarly group in interaction with the DSM-IV Task Force un- 
der sponsorship of the National Institute of Mental Health and the 
American Psychiatric Association. 



References 

Alarcon, R.D., (1983). A Latin- American perspective on DSM-III. Ameri- 
can Journal of Psychiatry, 140, 102-105. 

Alvarado, C. (1985). Funcion del soporte social en el desorden de adap- 
tacion. Anales de Salud Mental, 1 (Lima, Peru), 127-142. 

Becerra, R.M., Karno, M. and Escobar, J.I. (1982). The Hispanic patient: 
Mental health issues and strategies. In R.M. Becerra, M. Karno and J.I. 
Escobar (Eds.). Mental Health and Hispanic- Americans. New York: 
Grune & Stratton. 

Berrios, G.E. (1984). Descriptive psychopathology: Conceptual and histor- 
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Bustamante, J. A. (1961). Importancia del folklore en la psiquiatria. 
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Cantor, N., Smith, E.E., French de Salles, R., Mezzich, J.E. (1980). Psy- 
chiatric diagnosis as prototype categorization. Journal of Abnormal 
Psychology, 89, 181-193. 



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Cuellar, I. (1982). The diagnosis and evaluation of schizophrenic disorders 
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cobar (Eds.). Mental health and Hispanic Americans. New York: Grune 
& Stratton. 

Cuellar, I. and Roberts, R.E. (1984). Psychological disorders among 
Chicanos. In J.L. Martines and R.H. Mendoza (Eds.), Chicano psychol- 
ogy (2nd edition). Orlando, Florida: Academic Press. 

Escobar, J.L, Gomez, I. and Tuason, V.B. (1983). Depressive phenome- 
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Escobar, J.I. and Randolph, E.T. (1982). The Hispanic and social net- 
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Fabrega, H. (1975). The need for an ethnomedical science. Science, 189, 
969-975. 

Fabrega, H. (1988). Statement in panel on ICD-10. In J.E. Mezzich and 
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Part III 



Primary Prevention 
and Treatment 



I 









11 



Toward Combined Prevention and 
Treatment Services for Major Depression 

Ricardo F. Munoz, Ph.D. 



The major goal of the workshop which led to the present mono- 
graph was to define a future research agenda for meeting the men- 
tal health needs of the Hispanic population of the United States. 
Another goal was to inform and to motivate young mental health 
professionals to develop skills to address these needs. 

This paper will address an area which has been consistently under- 
emphasized in mental health research and practice, namely, preven- 
tion. Illustrations of a preventive approach will focus on one dis- 
order: major depression. It is my contention that, unless preventive 
services for Hispanics and others are developed and carefully evalu- 
ated, we will not be able to reduce the prevalence of major depres- 
sion. It is my hope that mental health professionals will find this 
argument convincing and that, at least some of them, will decide to 
devote significant portions of their professional energies to making 
prevention interventions an accepted part of mental health services. 

To reduce the prevalence of major depression in Hispanics in the 
United States, it will be necessary to go beyond treatment services. 
This paper will present the rationale for focusing on prevention, rea- 
sons why prevention services may be particularly needed in Hispanic 
groups, limitations of treatment services, and the need to develop 
methods which can reach the majority of people who need them, 
rather than merely those who are willing to comply with profes- 
sionally-defined service delivery. Given economic and institutional 
limitations, prevention services are most likely to be developed if 
combined with treatment efforts. Some specific strategies for im- 
plementing prevention programs will be described. 

The goal of mental health services is to reduce the prevalence (i.e., 
the total number of cases) of mental disorders. This can best be done 
by a combination of successfully treating existing cases of the dis- 
orders and preventing new cases from developing. The former is 



1 84 Latino Mental Health 



treatment, the latter is prevention. At present, the mental health sys- 
tem relies entirely on treatment approaches. I will examine the na- 
ture of the problem, using demographic and epidemiologic data to 
estimate the prevalence of major depression in Spanish-speaking 
Hispanics, and whether treatment approaches to reducing prevalence 
are feasible. 

How many adult U.S. Hispanics suffer from major depression? 

To answer this question, we need estimates of the number of adult 
Hispanics in the United States and of the rates of depression found 
in epidemiologic studies. Given that Hispanics belong to several 
major national and cultural groups, epidemiological rates for each 
of the major groups will need to be estimated. 

Population census figures indicated that out of a total of 21 ,437,000 
Hispanics in the United States, 65% (approximately 14 million) are 
18 years old or older; 50.2% are male; and 62.6% are estimated to 
be of Mexican origin, 11.1% Puerto Rican, 4.9% Cuban, 13.8% 
Central and South American, and 7.6% "Other Hispanic" (U.S. 
Bureau of the Census, 1991, 2). The population figures of the U.S. 
Bureau of the Census (1991) in Table 1 were derived by multiplying 
the estimates for each group by the percent of those 18 years and over 
for that group and then by the percent of males and females for the 
same group. 

Moscicki et al. (1987) provide six-month prevalence rates for 
major depression, as follows: Mexicans, 1.0 for males, 3.6 for fe- 
males; Puerto Ricans, 3.4 for males, 7.4 for females; and Cuban 
Americans, 1.4 for males, 2.9 for females. Estimates for Central and 
South Americans and "Other Hispanics" are unavailable, and thus 
will be conservatively estimated by using the Cuban rates. Rates for 
residents of Puerto Rico are based on reports by Canino et al. (1987) 
are 2.4% for males and 3.3% for females. It appears from these offi- 
cial figures that there are well over 100,000 Hispanic men and ap- 
proximately 300,000 Hispanic women who meet criteria for major 
depressive episodes during any six-month period in the United States 
and Puerto Rico. Table 1 presents the results of these estimates. 

How many persons with major depression need 
Spanish-speaking services? 

The proportion of Hispanics whose primary language is Spanish 
varies across groups and geographical regions. The proportion of 
Mexican-Americans who completed the UCLA ECA interview in 



Toward Combined Prevention and Treatment Services 185 



Table 1. Number of Hispanics in the United States and Puerto Rico 
meeting criteria for Major Depressive Disorder (MDD) 
during a six-month period. 



All Hispanics (100%) 
(18 years and older) 


Males 


MDD 


Females 


MDD 


Total MDD 


Mexican Origin 


4,301,592 


43,016 


4,099,954 


147,598 


190,614 


Puerto Rican 


713,192 


24,249 


794,614 


58,801 


83,050 


Cuban - 


442,885 


6,200 


430,655 


12,489 


18,689 


Central & 
South American 


970,652 


13,589 


1,038,979 


30,130 


43,719 


Other Hispanic 


563,633 


7,891 


588,991 


17,081 


24,972 


Total Depressed 
(in the 50 States) 




94,945 




266,099 


361,044 


In Puerto Rico 
(17 to 64 years old) 


851,000 


20,400 


941,000 


31,000 


51,400 



Source: 

U.S. Bureau of the Census, Current Population Reports. (March 1991). The 
Hispanic population in the United States, Series P-20, No. 455 (Washington, D.C.: 
U.S. Government Printing Office), p. 2. 



Spanish was 47% (Burnam et al., 1987). In San Francisco, commu- 
nity studies of Latinos have reported that between 70% to 83% 
(Lang et al., 1982) of respondents chose to complete interviews in 
Spanish. Assuming that 60% of adult Hispanics in the United States 
are primarily Spanish-speaking, and thus would need mental health 
services in Spanish, and using the figure of 361,044 total depressed 
Hispanics (refer to Table 1), we can estimate that well over 200,000 
adult Spanish-speaking persons (60% of 361,044 is 216,626) require 
treatment for depression in any six-month period within the 50 states. 
We will use the 200,000 figure as a conservative estimate in what 
follows. 

How many Spanish-speaking therapists are there 
in the United States? 

Figures for psychologists were available from the National Science 
Foundation (1988). The good news is that between 1977 and 1987, 
the proportion of employed doctoral-level psychologists who iden- 
tify themselves as Hispanic doubled. The bad news is that the actual 
figures were 0.9% in 1977 (300 out of 33,700 psychologists nation- 
wide), and 1.8% in 1987 (1,000 out of 56,400 nationwide). Since 



186 Latino Mental Health 



37% of psychologists are in the clinical area, and another 15% in 
counseling (National Science Foundation, 1988), we can estimate 
that 370 are clinical psychologists and 150 counseling psychologists 
for a total of 520 in mental health services. 

The assumption that all 520 speak fluent Spanish will now be made 
in order to account for the fact that figures for other therapists, such 
as social workers and psychiatrists, were not available to the author 
and that some non-Hispanic therapists speak Spanish. Otherwise, 
using the earlier 60% figure of Spanish-speaking persons within the 
Hispanic community, we would have arrived at 312 as our figure. 

How many Spanish-speaking persons with major depression 
could be treated by the estimated 520 Spanish-speaking therapist? 

The newer, brief psychological treatments for major depression 
requires 20 one-hour sessions. In six months (26 weeks), at 40 hours 
of patient contacts per week (for a total of 1040 hours), a profes- 
sional could provide individual treatment for 52 patients. Leaving 
some time for vacations and such, 500 psychologists seeing 50 pa- 
tients each could treat 25,000 depressed patients in six months. This 
would leave 175,000 untreated Spanish-speaking cases of major 
depression. 

Note that the above estimates assume that Spanish-speaking ther- 
apists would only treat adults with major depression. No children 
or adolescents would be seen nor patient with other disorders. 

How effective would prevention efforts have to be to 
be comparable to treatment efforts? 

Focusing for the moment only on the 200,000 cases of major 
depression estimated to occur in any six-month period in Spanish- 
speaking U.S. adults, we find that a reduction in incidence of as little 
as one-eighth would match the 25,000 cases that could be treated by 
all the available Spanish-speaking U.S. therapists. 

How large is a reduction of one-eighth in terms of incidence? For 
illustrative purposes, one could set a one year incidence for major 
depression at 4% (it is actually somewhat less than that). One-eighth 
of 4% is 0.5%. Thus, a one-eighth reduction would result in an in- 
cidence of 3.5%. It should be clear that even a relatively small 
prevention effect can easily rival that of treatment, even assuming 
treatment was 100% effective. 






Toward Combined Prevention and Treatment Services 187 



How effective are current treatments for depression? 

The most carefully conducted studies of the effect of treatments 
for depression are randomized controlled trials. It is very likely that 
such trials provide an over estimate of efficacy. Even with this posi- 
tive bias results are far from satisfactory. 

The sources of positive bias in treatment outcome studies are 
many. Therapists are carefully selected, systematically trained and 
continuously supervised. It would be rare for this type of careful 
selection and supervision of treatment to occur in either public or 
private clinical services. In addition, a research team is likely to be 
motivated to obtain good results which are intended to be made pub- 
lic. Most therapists outside the context of research do not keep ac- 
curate records of overall effectiveness, and, even if maintained, they 
generally would not disclose such data. For these reasons, it is likely 
that therapists in research studies would perform at the upper range 
of potential effectiveness. 

Patients, too, are carefully selected. To begin with, only 20% of 
those who meet criteria for major depression seek treatment (Shapiro 
et al., 1984). Furthermore, only a small percentage of patients seek- 
ing treatment are likely to choose to become subjects for research 
studies. The effects of this as a selection factor is unknown, but is 
likely that researchers select for motivated patients. 

From the researcher's side, there is further selection; only about 
10% of those who inquire about clinical trials are even scheduled for 
evaluation (Bellack & Hersen, 1981), and about 36% to 45% of those 
evaluated are accepted into the trial (DiMascio et al., 1979; Elkin 
et al., 1989; Murphy et al., 1984;). Often the studies have several ex- 
clusion criteria, including physical illness, illiteracy, ability to speak 
English, and so on. In addition, of course, patients who have trouble 
keeping appointments will select or eliminate themselves from the 
studies by never completing the evaluation phase. By the time the 
preliminaries are over, the study sample is likely to be made up of 
subjects who are motivated, compliant, relatively well-functioning, 
probably well educated, and with sufficient resources to afford 
repeated travel to the clinical site. In addition, they would have 
enough control over their own personal time to attend sessions. 
These characteristics are likely to give the treatments being tested a 
higher likelihood of showing positive effects than if they were im- 
plemented with a representative sample of the general public, or with 
persons who use public sector clinics. 



188 Latino Mental Health 



How positive are the reported effects? 

Dropout rates from treatments are considerable. Attrition usually 
produces dropout rates between 20% and 52% (DiMascio et al., 
1979; Simons et al., 1984). In the National Institute of Mental Health 
Collaborative Study (Elkin et al., 1989), 88 (35%) out of 250 ran- 
domized patients dropped out; 1 1 dropped out before treatment 
started and another 77 during treatment. The proportion of patients 
who recovered ranged between 36% to 56% for all who entered 
treatment, and between 51% to 70% for all who completed at least 
15 weeks of treatment; sustained improvement is poor, even for 
those who recover. 

In the Murphy and Simons study (Murphy et al., 1984; Simons 
et al., 1986), out of 95 randomized patients, 25 (26%) dropped out; 
of 70 completers, 44 (63%) responded; and, out of 44 who 
responded, 28 (64%) did not relapse within one year. Thus, of 95 
randomized patients (after careful screening), only 28 (29%) were 
remitted at a one year follow-up. 

In addition to the low utilization and less than satisfactory effec- 
tiveness of treatment, there are some drawbacks and risks to enter- 
ing treatment. There is the stigma of becoming a "mental patient", 
which is particularly salient in Hispanic populations, but which has 
in fact been known to have serious effects on the individual careers. 
Perhaps the most celebrated example of this occurrence in recent 
times was the almost forced withdrawal of Senator Eagleton (D- 
Missouri) as a vice-presidential candidate when it was disclosed he 
had received treatment for depression. Other risks involved in cer- 
tain treatments range between relatively minor side effects, all the 
way to the potential use of antidepressants to commit suicide. 

We can conclude, then, that treatment for depression has several 
limitations and some risks. Even if the 25,000 Spanish-speaking per- 
sons were treated, out of the over 200,000 Spanish-speaking persons 
who need treatment for major depression, only about two-thirds 
would complete treatment. Furthermore, up to about two-thirds of 
those completing treatment would respond well, and less than a third 
(approximately 8,000 of the 25,000) would be well one year later. 

To match this level of performance, prevention programs would 
only have to reduce incidence rates by l/25th (8,000 well cases at one 
year divided by the original 200,000 Spanish-speaking cases). Reduc- 
tions greater than this would have a markedly greater impact than 
all available treatment services. From an alternative point of view, 



Toward Combined Prevention and Treatment Services 189 



given that all currently available therapists would only produce 8,000 
well cases after one year, if prevention programs were to reduce in- 
cidence in Spanish-speaking populations by 20% (40,000 cases), this 
would be the equivalent of providing five times as many Spanish- 
speaking therapists as are estimated to be currently available. Seen 
from this perspective, it seems eminently reasonable to try to develop 
effective prevention methods which can reach large segments of the 
population. 

Can major depression be prevented? 

In a recent review of the state of research and practice focusing 
on the prevention of depression (Munoz, 1993, a), it was found that 
only one randomized prevention trial attempted to test whether in- 
cidence of major depressive episodes could be reduced (Munoz et al., 
1987). However, the sample size was insufficient to properly test this 
hypothesis given the incidence found. A clear priority for future 
research is the need for more randomized, controlled prevention 
trials with sufficient statistical power to document reduction in 
incidence. 

There are a number of studies, however, which together give am- 
ple evidence that depressive symptoms can be reduced in initially 
non-clinical populations (Munoz, 1993, a). It is not too great an 
extrapolation to suggest that maintaining depression levels below 
clinical thresholds can reduce the rate of new clinical episodes. The 
hypothesis that these preventive effects (i.e., fewer numbers of new 
cases) can be produced by reducing symptoms of depression in non- 
clinically depressed individuals is definitely worth testing. 

The kinds of studies needed to properly answer this question 
would involve intervention trials with Spanish-speaking populations. 
On the other hand, professionals able to design the proper interven- 
tions and research studies to test preventive effects are in short sup- 
ply, and Spanish-speaking professionals with these skills are even 
more rare. The preparation of such individuals should be a major 
emphasis in graduate training (Munoz, 1993, b). 

Moving forward in time for a moment, we can imagine that such 
studies have taken place and that they have supported our predic- 
tion that incidence decreases when depression symptom levels can 
be reliably reduced. Would this be sufficient? If professionals are 
engaged in direct provision of prevention services, and especially if 
these services are delivered to small groups of individuals, the impact 



1 90 Latino Mental Health 



on incidence would be minimal. We would have the same problems 
of having limited numbers of professionals with minimal impact on 
the population as a whole. 

What is needed to make prevention feasible is a combination of 
effective interventions and delivery strategies which can reach the 
people who need them the most. Utilization rates for mental health 
services are extremely low for all ethnic groups, but they are even 
worse for Hispanics. Data from the Epidemiological Catchment 
Area Los Angeles site (Hough et al., 1987) is probably the clearest 
comparison of utilization by diagnosed persons. It shows that among 
those with a diagnosable mental disorder, only 22% of non-Hispanic 
Whites sought care from mental health providers, compared to 11% 
of Mexican- Americans. Therefore, it is important that comprehen- 
sive mental health services not be delivered only to easily available 
populations. Service delivery methods must be developed which will 
reach those most at risk, even if that means creating services which 
can be used at their convenience and in their own homes. 

Expanding mental health services beyond the professional office: 
A framework for research and practice. 

Table 2 presents a grid in which the columns represent three 
chronologically ordered services which ideally ought to be part of 
a complete mental health care system: prevention, treatment, and 
maintenance. The rows represent six possible means of service de- 
livery: professionals, paraprofessionals, partner-companions, peer 
clients, paraphernalia, and print. At present, most resources are 
devoted to one of the resulting 18 cells: treatment by professionals. 
Attention needs to be given to the development and evaluation of 
service delivery methods which involve the other 17 cells (Christensen 
et al., 1978; Munoz, 1982; Munoz, 1980). 

Prevention. Prevention refers to interventions for persons who do 
not meet criteria for clinical disorders, but who are at risk for de- 
veloping such disorders. The intent of preventive interventions is to 
reduce the incidence of the disorders. 

Treatment. Treatment refers to interventions administered to per- 
sons who already meet criteria for the disorder and are intended to 
cure the disorder or to stop its progression to more severe levels. 
Early case finding (usually termed "secondary prevention") actu- 
ally fits into the treatment realm. Treatment interventions aim at 
reducing prevalence by terminating clinical episodes. There are dis- 



Toward Combined Prevention and Treatment Services 



191 



Table 2. A Framework for Research: Expanding Mental Health 
Services Delivery 





Prevention 


Treatment 


Maintenance 


Professionals 








Paraprofessionals 








Partner-companions 








Peer Clients 








Paraphernalia 








Print 









orders, however, which are chronic or cyclical in nature. In these 
cases, continuing care is required. 

Maintenance. Maintenance refers to such types of care in which 
the aim is to reduce the level of dysfunction, provide support for the 
patient, and perhaps prevent acute exacerbations of the condition. 
Maintenance services do not reduce prevalence; in fact, they may ac- 
tually increase prevalence for disorders which would generally end 
in early death of the victim. When effective, maintenance services 
do reduce disability in those affected. 

The five additional service delivery methods need some descrip- 
tion, and they have been given alliterative names as a mnemonic 
device (Christensen et al., 1978): 

Paraprofessionals are here defined as persons with specialized 
training in the administration of specific interventions but who do 
not have a degree and license that permits them to engage in indepen- 
dent mental health practice. They are, however, paid for their work. 
Such persons might have a bachelor's degree in psychology and have 
training in teaching deep muscular relaxation procedures to primary 
care patients about to undergo anxiety-producing procedures. 

Partner-companions may be defined as volunteers who share 
knowledge gained through their past life experiences with people who 
are currently facing similar experiences. For example, these might 
be immigrants who have been in the U.S. for 10 or more years. Ad- 
ditionally, they are individuals who meet with groups of recent im- 
migrants to provide information, support, and advice on how 
persons cope with this stressful time. Partner-companions are clearly 
in a helping role. 



1 92 Latino Mental Health 



Peer-clients are defined as persons in mutual help groups. All par- 
ticipants in services of this nature would be considered to be "in the 
same boat" and the source of preventive or therapeutic effect comes 
from sharing experiences with others in the same situation. For ex- 
ample, a support group for Hispanic freshmen at a university would 
fit here. There are several successful examples of this level of inter- 
vention such as Alcoholics Anonymous. 

Paraphernalia. Paraphernalia refers to equipment, gadgets, the 
mass media, and other adjuncts by which information, individual- 
ized programs of self-change, and interactive training methods can 
be administered. For example, a television program focused on ways 
to reduce depression level would fit here (Munoz, Glish, Soo-Hoo 
& Robertson, 1982). Computer applications for prevention and treat- 
ment are an untapped source of individualized interventions, which 
will gradually come into their own. It is important that such advances 
be adapted to Spanish-speaking populations, to pre-literates, and to 
persons unable to attend services away from home, for example, be- 
cause they provide child care to grandchildren. 

Print refers to the written word, illustrated manuals, and other 
sources of information and guidance. Such materials are widely 
available for English-speaking persons, and they need to be deve- 
loped for others (Munoz, 1982). More importantly, materials 
designed to have preventive effects in the mental health area need 
to be carefully prepared and evaluated. 

Proposed Framework and Implications of Adjuncts 

The are many underlying ideas in the format for the proposed 
framework. The implications of the adjuncts included in it are as fol- 
lows (Christensen, 1979): 

1 . Adjuncts are more plentiful and less costly than professionals. 

2. Adjuncts can maintain greater contact with clients in their 
natural environments. This is especially true for paraphernalia and 
print, which can be used at the individual's convenience. 

3. Professionals, especially Spanish-speaking professionals of 
whom there are still so few, should devote significant time to super- 
vision, program development, training, diagnosis, and evaluative 
research, and not just to direct services. 

4. Evaluation is essential at all levels of the proposed framework. 
It must not be assumed that any one level is effective for any problem 
and any population. Intervention at one level will not necessarily be 
effective when applied at another level of the framework. It is pos- 






Toward Combined Prevention and Treatment Services 193 



sible that some lower levels in the framework will be more effective 
and certainly more efficient than higher levels. For example, mass 
media approaches, even if proportionately less powerful than direct 
personal services, might have more impact on the population given 
the greater number of persons who are affected by it. A television 
intervention, in this instance, which produces a 2% reduction in in- 
cidence for an audience that includes 100,000 people at very high 
risk, has more numerical impact (2,000 fewer cases) than for a small 
group intervention with 50% reduction in incidence which is only 
available to 200 people at the same level of risk (100 fewer cases). 
5. A lower level adjunct (i.e., a less expensive one) can be used 
as a minimal standard against which to evaluate interventions higher 
in the framework. Since each level may be useful for different seg- 
ments of the population, many more persons will be effectively 
served by the more plentiful and less expensive adjuncts. The more 
difficult cases will still need to be seen by well-trained professionals. 
Functions which will gain importance for the professional include 
developing and providing the adjuncts, matching clients and services 
and evaluating the effectiveness of the adjuncts. 

Is there any evidence that the use of adjuncts is feasible 
and that it can produce measurable effects? 

Most mental health studies focus on the effect of professional in- 
terventions on the treatment of disorders. There are some research 
projects, however, which have published findings relevant to the pro- 
posed framework. 

Paraprofessionals. The Hispanic Social Network Prevention In- 
tervention study recruited natural caregivers in a Mexican commu- 
nity and trained them in the delivery of cognitive-behavioral methods 
to prevent depression (Vega et al., 1987). The process of training and 
the delivery of the intervention went relatively well. Results indicate 
that women with low levels of depression at the beginning of the 
study benefitted most from the intervention. 

Partner-companions. Although I am not aware of studies actu- 
ally showing measurable mental health effects, there are several on- 
going programs which routinely use this level of intervention. 
Rapport et al. (1979) reported on the successful use of college stu- 
dents as companions for juveniles on legal probation. The students 
were trained to provide social learning oriented behavioral contract- 
ing and advocacy skills. The amount and seriousness of police con- 
tacts were markedly reduced for the experimental group when 



1 94 Latino Mental Health 



compared to a randomly assigned control group. The Big Brother 
and Big Sister programs pair responsible adults with children in high- 
risk situations. The popularity of the program shows that the idea 
is definitely feasible. An evaluation of effect would be interesting, 
perhaps using waiting lists as controls. Widow-to-widow programs 
have also been put into practice in which newly-bereaved women are 
contacted by women who have undergone the experience of losing 
their spouses, and who can offer ongoing support (Silverman & Mur- 
row, 1976). I do not know whether such programs are available for 
the Spanish-speaking. 

Peer-clients. Alcoholics Anonymous, AA, is considered an impor- 
tant resource among professionals working with alcoholics. As with 
most types of treatment approaches, it requires acceptance of its un- 
derlying philosophy, namely the twelve-step process; thus, it is not 
appropriate for everyone. The great number of mutual support AA 
groups across the nation, (including Spanish-speaking AA groups), 
however, speak well for the feasibility of the idea. There is also a 
large self-help movement (Riesman et al., 1986), which suggests that 
large segments of the population are willing to participate in such 
groups. Active participation in such groups has been reported to have 
positive effects on mental health variables (Lieberman & Borman, 
1981). 

Paraphernalia. Television messages have been shown to have 
measurable effects on psychological variables. Behavior and mood 
showed intended changes in a randomly selected sample of San Fran- 
cisco residents who had seen a series of spots on how to manage 
one's mood (Munoz, Glish, Soo-Hoo & Robertson, 1982). Alcohol 
consumption was reduced through television advertising in Australia 
for respondents who had been sensitized to the ads with a letter 
(Barber et al., 1989). Additionally, computer-administered cognitive- 
behavioral treatment produced significantly greater decrease in 
depressive symptoms than a waiting-list condition and no differ- 
ences from therapist-administered cognitive-behavior therapy (Selmi, 
1990). 

Print. Mildly and moderately depressed older adults received cog- 
nitive, or behavioral bibliotherapy or delayed treatment. Both ac- 
tive treatments showed significant decreases in symptoms compared 
to the delayed condition and no differences from each other. Gains 
were maintained at six-month and two-year follow-ups (Scogin et 
al., 1989; Scogin et al., 1990). 



Toward Combined Prevention and Treatment Services 195 



Recommendations 

To address the problem of depression in Hispanics, interventions 
which go beyond treatment by professionals must be developed and 
evaluated. Specifically, it is crucial to focus on prevention and on 
the development and implementation of adjuncts to expand men- 
tal health service delivery. 

It is particularly important that the advances being made in terms 
of the use of technology in mental health be made available to the 
Spanish-speaking population from the outset. It is important not to 
continue playing "catch-up" in this area, as in most others. It is con- 
descending to suggest that Hispanics can not respond to the most 
technologically advanced methods of intervention. What is needed 
are professionals committed to adapt technology in a culturally rele- 
vant manner, as well as devising ways to expose Spanish-speaking 
consumers to the technology so that they have a chance to learn how 
to use it. 

For example, with the use of analog-to-digital "speech boards," 
computers could be used to routinely screen primary care patients 
for depression. This may be accomplished by having the computer 
present the screening questions verbally and by programming the 
computer to accept the person's verbal responses (Starkweather & 
Munoz, 1989). This method would be particularly helpful because 
medical staff are usually too busy to add another screening proce- 
dure to their protocol. It would be essential for monolingual, 
Spanish-speaking patients in clinics where there are few or no 
Spanish-speaking providers. The results of the screening procedure 
could be printed out and made available to the primary care 
provider. Even if providers could not intervene, at least the condi- 
tion would have been identified and the process of locating ap- 
propriate help would begin. For mild and moderate cases of 
depression, interventions modeled after the computerized or biblio- 
therapeutic interventions described above could be made available 
to such patients (Selmi et al., 1990; Scogin et al., 1989; Scogin et al., 
1990). 

The introduction of new services is always problematic, and 
prevention is no exception. Preventive interventions are most likely 
to be accepted if combined with treatment services. Consider the fol- 
lowing scenario: combined prevention and treatment services in a 
primary care clinic could be established and maintained under the 
following conditions. Each primary care clinic serving Hispanics 



196 Latino Mental Health 



could routinely provide screening and triage for major depression. 
Such screening could be accomplished with paper-and-pencil self- 
report depression scales, such as the CES-D, Center for Epidemio- 
logical Studies Depression Scale (Radloff, 1977), or the BDI, Beck 
Depression Inventory (Beck et al., 1961), or with computerized ver- 
sions of such scales described above. 
The screening system would identify three groups: 

1 . ''Depressed," or those with high enough depression scores to 
be likely to meet clinical criteria for depression and thus in need of 
professional evaluation. It would be possible to set up a computer- 
ized system, which automatically checks for the presence or absence 
of symptoms for major depressive episodes, melancholia, or suici- 
dality, if a person scores above a certain cut-point on the screening 
scale. Although final diagnosis and disposition would still require 
a professional interview, the Spanish-language diagnostic interview 
could certainly be computer-assisted (Aguilar-Gaxiola, 1991). 

2. "High risk" group infers that it is unlikely to currently meet 
criteria for clinical depression, but there are a sufficient amount of 
risk factors to recommend preventive intervention. Risk factors 
might include personal history of depression, family history, high 
symptom level, and high number of stressful life events. 

3. "Low risk" group infers that it is neither currently depressed, 
nor associated with high risk factors. This group would be left alone 
once the screening procedure has been validated. 

Once the screening procedure has taken place, triage would oc- 
cur. Patients in the "depressed" category would be seen by a men- 
tal health professional, and diagnosed and referred to emergency 
services if acutely suicidal, psychotic or unable to care for self; out- 
patient treatment (if patient agrees); antidepressant treatment by the 
primary care provider (if the patient refuses to see a specialist); and, 
if the patient has mild to moderate levels of depression and is not 
suicidal, to any of the "adjuncts" discussed in the above framework, 
such as: paraprofessional instructor on mood management, volun- 
teer support person, mutual aid (self-help) group, audio or video 
materials on mood management, self-administered computerized 
treatment, or printed self-help manuals. Patients in the "high risk" 
category would be given information about courses in mood 
management, support groups, audio or video materials, computer- 
ized preventive self-change programs and printed depression preven- 
tion programs. 






Toward Combined Prevention and Treatment Services 197 



The development and evaluation of such interventions will require 
professionals trained in a number of areas: high risk factor research; 
outreach methods to attract and intervene with populations at risk, 
rather than merely with available populations; development of in- 
terventions; computer applications; evaluation research; developing 
comprehensive programs across mental health; primary care; and 
occupational, economic, and educational settings. In order to serve 
many Hispanics, such professionals will need to also be bilingual and 
bicultural. There is much to be done. 

A Parting Thought-Problem 

Currently, most cases of depression are not being detected, even 
by primary care professionals (Perez-Stable et al., 1990). Even so, 
the mental health treatment system, especially in the public sector, 
is unable to meet the demand. Long waiting lists are very common. 
What will we do with all the cases that the screening process 
described above will uncover? Deciding not to find the cases is not 
an acceptable solution. 



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Preventing Depression in the 
Hispanic Community: An Outcome 
evaluation of projecto blenestar 

William A. Vega, Ramon Valle, Bohdan Kolody 



The idea that the mental health of this nation is a legitimate public 
health concern, and that services should be organized on a very 
broad scope, was formally recognized in the Community Mental 
Health Centers Act of 1963. President Kennedy, in his report to Con- 
gress in 1963, issued an inspiring challenge to take up a determined 
"assault" on mental illness by providing universal access to services 
and by fusing new knowledge and expanded resources for achiev- 
ing bold and innovative interventions (Congressional Record, 1963). 
Prevention of mental disorder was now seen as an attainable goal 
and as a core element of comprehensive community mental health 
planning. Unfortunately, there existed a scarcity of theory or com- 
munity experience on which to model new community-based preven- 
tive interventions (Vega & Murphy, 1990). As a result, prevention 
was widely recognized as a laudable activity, but it sparked little 
practitioner interest or serious research. 

In 1978, experts were convened by President Carter to review the 
state of the art in mental health services. They found little progress 
in the development of prevention programs within the community 
mental health experience. In assessing the impasse, The Report of 
the Task Panel on Prevention (Presidential Commission, 1978) called 
for a paradigm shift toward primary prevention. The change of focus 
was necessitated, according to the panel, because it was not deemed 
desirable or possible to meet the mental health needs of the nation 
by traditional clinical treatment. According to the Report, the crit- 
ical point is that while all behavior has an underlying physiological 
basis, disturbed behavior need not imply an underlying pathologi- 
cal organic process. Therefore, primary preventive interventions 
aimed at carefully selected risk groups were urged in order to 
strengthen coping capabilities. Presumably, these interventions 
would have the effect of lowering the incidence of mental disorders 



202 Latino Mental Health 



within these targeted groups. Of course the repeal of the Commu- 
nity Mental Health Centers Act in 1981, and the initiation of the 
Block Grant Program, dimmed any hope that prevention might be 
taken more seriously within the community mental health movement 
(Public Law, 1981). Nevertheless, in the early 1980's, the National 
Institute of Mental Health committed itself to encouraging the de- 
velopment of prevention trials in a variety of settings and for diverse 
risk groups. 

This historical summary provides a context for understanding how 
Projecto Bienestar came into existence, since it was funded as an un- 
solicited research application by the Center for Prevention Research 
of the NIMH, as part of an initiative which also included establish- 
ing prevention research centers and enumerating prevention activi- 
ties within state departments of mental health. To our knowledge, 
Projecto Bienestar remains as the only example of a large ran- 
domized trial conducted in the Hispanic community. The rekindled 
interest in prevention at the NIMH was met with apprehension 
by many researchers and practitioners. The disenchantment was 
grounded in the belief that resources would be pulled away from clin- 
ical research and services when not enough was known about the 
etiology of psychiatric disorders to justify preventive interventions, 
and what was known about etiology seemed to make primary 
prevention unfeasible or impractical. As a result, to these skeptics, 
prevention efforts were, and are, a waste of time and money. 
Curiously, traditional psychotherapy and even psychopharmaco- 
logy were not attacked on similar grounds although they suffered 
similar limitations. Criticism notwithstanding, prevention trials went 
forward revealing much about the science and the practice of men- 
tal health intervention. This paper is devoted to presenting an out- 
come evaluation of Projecto Bienestar. However, before doing so, 
it would beneficial to briefly inform readers about the intellectual 
guideposts that led to the development of Projecto Bienestar. 

The Intellectual Context for Prevention Research 

Emile Durkheim (1951), in his landmark 19th century study of sui- 
cide, noted an association between social change, personal adapta- 
tion and severe mental distress. Indeed, a fundamental postulation 
of Durkheim was that the movement of individuals away from en- 
vironments characterized by social homogeneity of behavioral ex- 
pectations and values, and their insertion in complex environments 
rife with conflicting normative expectations, were personally disor- 






Preventing Depression in the Hispanic Community 203 



ganizing. The notion that environmental factors could have a per- 
vasive effect on the behavior of individuals, especially in areas 
undergoing rapid changes, were again borne out by the social area 
studies of Faris and Dunham (1939) as well as a host of other 
Chicago-based researchers in the 1920s and 1930s. These investiga- 
tors discovered that certain areas of Chicago were socially disor- 
ganized and disproportionately characterized by mental deviancy, 
alcoholism and criminal behavior. Moreover, it was found that these 
trends persisted despite changes in the ethnic and racial composition 
of these areas over time, suggesting an etiologic role for environmen- 
tal factors in nurturing or sustaining pathological behaviors. 

The advent of large community surveys, such as the Midtown 
Manhattan Study in the mid- 1 950' s, revealed an inverse relationship 
between socioeconomic status and psychological distress (Srole et 
al., 1962). This finding soon became axiomatic in the field. Re- 
searchers were convinced that environments could contribute to 
producing mental illness even if empirically demonstrating how this 
process occurred remained unclear. In 1962, Rodgers called for 
general preventive measures directed at the determination and con- 
trol of the underlying pattern of environmental relationships. This 
belief was reflected by numerous writers during this period which 
provided a philosophical grounding for the federal community men- 
tal health center movement undertaken in 1963 and was reflected in 
naming some state mental health hygiene agencies "Departments of 
Mental Hygiene" (Wagenfeld et al., 1982). 

An important development was the formulation of social psycho- 
logical stress theory. Although the work of Selye (1956) on the 
General Adaptation Syndrome remains controversial, there is no 
doubt that this body of research had far reaching implications for 
mental health theory about personal adaptation. Despite the fact that 
Selye did not explicitly link emotional and cognitive factors to stress, 
his model opened the door to conceptualizing social psychological 
stress models. Subsequent efforts include, for example, the exten- 
sive and continuing research about coping processes undertaken by 
Lazarus (1966), or the more recent work of Pearlin and Schooler 
(1978), which focused on isolating persistent strains and coping 
responses in various domains of life activity. Stress process 
researchers have focused on the transactional nature of environment 
and personal adaptation and opened the door to public health in- 
terventions based on selective strengthening of coping resources for 
carefully selected risk groups (Goldberger & Breznitz, 1982). 



204 Latino Mental Health 



There are two additional developments that also form part of the 
intellectual heritage of contemporary intervention research, and these 
are closely linked to stress process research. The first is the exten- 
sive and complex literature about social networks and social support. 
Although there are many aspects to this research, perceived support 
is widely accepted as a coping resource which helps offset the de- 
bilitating effects of environmental stress (Dean & Ensel, 1982; Gore, 
1969). A second major development was the refinement and oper- 
ationalization of social learning theory by Bandura (1977, 1982), 
which underscored the importance of social reinforcement in be- 
havior change moderated by the agency of self-efficacy. Key to be- 
havior change was the availability of supporting individuals to 
provide modeling of new behaviors and a setting for rehearsing new 
behaviors and receiving social approval for improving and maintain- 
ing performance levels. These two literatures were essential for 
facilitating the era of community based preventive interventions. 

Nevertheless, despite the advent of this formidable body of 
knowledge, it is of utmost importance to note that little attention 
has been paid during the previous three decades to the role of cul- 
tural factors in the development of intervention theory. As result, 
there is a tendency to use "off-the-shelf" interventions models and 
materials without sufficient regard for cultural expectations or prac- 
tices. This was the pitfall that Projecto Bienestar investigators took 
great care to overcome in all phases of data gathering and interven- 
tion tasks. 

Conceptualization of Projecto Bienestar 

Despite the important contributions to Projecto Bienestar from 
the literature noted above, there remained serious gaps in knowledge 
required for conducting this intervention. The first aspect of this was 
the selection of a risk group for intervention. Previous epidemiologic 
studies conducted in California by Vega et al. (1984, 1985) identified 
low income, immigrant women of Mexican heritage as consistently 
at high risk for psychophysiological distress and depressive sym- 
ptomatology. Therefore, this cohort was selected for intervention. 

A second aspect was the inclusion of extensive ethnomethodolog- 
ical research completed by Valle and Mendoza (1978) and Valle 
(1985) on the cultural characteristics of Hispanic natural support sys- 
tems and natural helpers. This research was sufficiently comprehen- 
sive to permit social mapping of Hispanic communities and 



Preventing Depression in the Hispanic Community 205 



identification of various types of natural helpers, termed servidoras 
by these researchers. This expertise permitted casting the interven- 
tion within a culturally appropriate set of techniques for accessing 
and intervening with subjects, although there certainly remains much 
to be learned in this regard (Vega et al., 1987). In essence, their find- 
ings provided a method for cultural validation of all aspects of 
the study. 

The third aspect was derived from the necessity to identify per- 
sonal risk factors linked to depression in the target group and to de- 
termine which of these could be modifiable using a structured 
educational intervention. Although epidemiologic data was available 
from previous studies, this research failed to collect a wide spectrum 
of information needed to understand psychosocial processes as- 
sociated with risk in this population. For this type of information 
it was necessary to consult experts who had extensive clinical ex- 
perience within low income Hispanic communities in California. The 
most influential of these for this study were Dr. Marvin Karno and 
Dr. Teresa Boulette. 

In brief, the profile of risk that emerged was rooted in a complex 
of household and extra-household factors. Women in the target 
group (35 to 50 years of age) were entering a period of increasing bur- 
dens with diminishing resources; in short, high demand and low con- 
trol with a propensity toward personal powerlessness. The demand 
emerged from chronic economic and social marginality character- 
ized by husbands with unsteady employment or physical handicaps 
which reduced income and by the need to provide for large families, 
which included meeting the economic and child care needs of both 
their own households and those of adult children. Since these women 
are almost uniformly Spanish language monolinguals, and often 
their social role has been limited to homemaking, they are frequently 
at a disadvantage in dealing with family business outside the home, 
especially when this entails negotiating with English-language 
bureaucracies. Moreover, despite the fact that these women are often 
physically isolated from social contacts except with family members 
and a few neighbors, they will be confronted by the necessity of step- 
ping outside their accustomed domestic situation and into a larger 
community arena, in order to access resources, seek employment, 
or to solve various types of problems. In summary, there are two 
primary reasons for increasing demands on immigrant women in this 
cohort; in many instances, there is a decreasing viability of husband 



206 Latino Mental Health 



as head-of-household (or total absence of a husband in household) 
and often an overall increase in the number of problems that require 
attention in multigeneration extended families with low incomes. 

The availability of the right types of social support, including in- 
formational, resource redistribution, transportation, translation as- 
sistance, and emotional support are all key aspects of this situation. 
Whereas various types of tangible assistance are required to solve 
everyday problems in living, emotional support is the most impor- 
tant for maintenance of morale. And, as noted above, emotional 
support also facilitates the introduction of new information and be- 
havior change. 

The intervention was postulated as an "early preventive interven- 
tion" due to the difficulty and potential inappropriateness of using 
more traditional public health nomenclature, for example, "primary 
prevention" for mental health problems such as depressive symp- 
toms that have no clearly discernable point of onset. On the other 
hand, there is a an important distinction between preventing the on- 
set of depressive symptoms among those who are asymptomatic, or 
nearly so, and intervening with those suffering from severe and 
chronic depressive disorder. Projecto Bienestar attempted to reach 
women who were either asymptomatic or only experiencing mild 
symptomatology at the outset of the intervention. The aim was to 
prevent depressive symptoms from onsetting or increasing among 
women experiencing risk of depression. The risk-proneness of these 
women had been established in previous epidemiologic studies. In 
fact, the first stage household screening for Projecto Bienestar 
yielded a mean CES-D score of 16, which is the usual "caseness" 
cutpoint for this measure. 

Intervention Design and Procedures 

The objectives of Projecto Bienestar emulate the general interven- 
tion model described by Roskin (1982) which include (a) modifica- 
tion of the environment as it distresses and supports, (b) provision 
of opportunities for strengthening individual capacities for dealing 
with interpersonal relationships, (c) understanding and coping with 
anticipated critical development tasks, and (d) understanding and 
coping with unanticipated stressful life situations. 

In formulating the intervention process, several program compo- 
nents were needed in order to increase the women's sense of em- 
powerment. These included emotional bonding, ego strengthening, 



Preventing Depression in the Hispanic Community 207 



and introduction of new behaviors and skills needed for solving the 
types of redundant problems seen by immigrant women. Guiding 
this process would be social learning theory; especially its operation- 
alization by Bandura (1977, 1982) which requires development of 
constituent competencies and strong percepts of self efficacy. 

A three group design was used which included two intervention 
groups and a control. One intervention, referred to throughout the 
remainder of this chapter as the "El" modality, was a one-to-one 
intervention carried by natural helpers (servidoras) trained and su- 
pervised by Projecto Bienestar staff. The El modality attempted to 
replicate the protocol and cultural style of natural helpers found in 
the low income communities of Southern California. The El was 
called the "Linkperson" modality. Natural helpers were termed 
servidoras in this study using the original terminology of Valle and 
Mendoza (1978). The "E2" modality, referred to as the Merienda, 
was a peer group intervention organized and led by a servidora. Both 
the El and E2 used thematically similar educational materials, albeit 
with techniques adjusted for the differences in intervention contexts, 
e.g., group versus one-to-one. Each intervention was built around 
a model of 12 intervention contacts. However, some variation in this 
standard was inevitable in a naturalistic setting. For example, some 
E2 groups continued to meet even after servidora discontinued con- 
tact with them. The third group was a control that no had no struc- 
tured intervention, although the cohort maintenance techniques 
required periodic mailings over an extended period of time; this 
could be considered a low powered intervention. Readers desiring 
more information about the content of the intervention are en- 
couraged to consult previously published materials by Vega and 
Murphy (1990) and Vega et al., (1978). 

Design of the Study 

The research site in San Diego County is adjacent to the U.S.- 
Mexico border. The extreme southwestern portion of the county is 
situated directly across from Tijuana, Mexico. In order to develop 
a sampling frame, all block groups with a Hispanic population of 
25% or greater were selected and most of these were located along 
a 16-mile, north/south residential corridor which starts in downtown 
San Diego and ends in San Ysidro at the international border. This 
is a mixed land-use region combining residential, commercial and 
industrial uses in a wide strip paralleling the Pacific Ocean coastline. 



208 Latino Mental Health 



The 1985 population of San Diego County was 2,041,300. Approx- 
imately 14.8% (302, 1 12 persons) were of Hispanic origin. These es- 
timates do not include undocumented aliens. Project enumerators 
went door-to-door within selected block groups in order to identify 
eligible women, often covering these areas twice to assure complete 
coverage. 

The sample was identified in a two-stage screening process. Stage 
one involved screening approximately 40,000 households in block 
groups within the sampling frame in order to identify women who 
met criteria for inclusion in the study. These criteria included eth- 
nicity (Mexican- American), female gender between 35 to 50 years 
of age and low household income. The screening process was 
designed to include both immigrant and non-immigrant women. 
However, sampling only high density Hispanic block groups resulted 
in over 90% of enumerated women (N = 2157) being immigrants. 
An additional effort was made to omit all women with less than two 
years in the United States because of the confounding effects of early 
immigrant adaptation on our dependent variable, depressive 
symptoms. 

Table 1 details the design steps and subject loss at each stage. 
There were several reasons for subject loss before the second stage 
of screening. As seen in Table 1 , 465 women were eliminated from 
the study by using the cutpoint of 23, which represented one stan- 
dard deviation above the mean on the criterion instrument, The 
Center for Epidemiologic Studies-Depression measure (CES-D) 
(Radloff, 1977). Although Projecto Bienestar was designed to be an 
early preventive intervention, the mean of the sample was so high 
that the investigators decided to use a normative distribution exclu- 
sion procedure, thereby eliminating women with mean scores over 
23 on the CES-D. This approach was intuitively appealing because 
previous research had found that only people in that symptom range 
tended to exhibit chronicity of their depressive mood over time. 
Moreover, the second stage screening involved using the Diagnos- 
tic Interview Schedule (DIS) (Robins et al., 1981), including sections 
on major depression and anxiety disorders, in order to exclude from 
the sample women who had already experienced these problems 
sometime in their lives. First stage screening also involved eliminating 
women who were suffering from life threatening illnesses, or from 
post traumatic stress disorder following the McDonald's restaurant 
massacre in San Ysidro that occurred during the earliest phase of 
Projecto Bienestar. 



Preventing Depression in the Hispanic Community 



209 



Ultimately, 800 women were interviewed face-to-face in the second 
stage of screening which constituted the baseline measurement for 
the experimental design. As noted in Table 1, an additional 134 
women were removed from the sample because they met caseness 
criteria on the DIS, thereby leaving a residual sample of 655 women 
suitable for randomization into the three groups. It should be noted 
that two women died during the study and were excluded from the 
data base thereafter. Because we anticipated differential attrition 
from groups, random assignment to groups was weighted with the 



Table 1. Subject Loss from Screen to Randomization 







Numeric 


Numeric 


Loss as Percentage 






Loss 


Balance 


of Previous Balance 


Total Enumerated 




- 


2157 


- 


Eligibility screens 




500 


1657 


23.2 


CESD>23 




(465) 




(21.6) 


PTSD 




( 13) 




( 0.6) 


Income >Md 




( 22) 




( 1.0) 


Project Criteria 




106 


1551 


6.4 


Geographic Location 




( 94) 




( 5.7) 


Data Quality 




( 12) 




( 0.7) 


Subject Reasons 




751 


800 


40.4 


Moved 




(239) 




(15.4) 


Could not contact to 










arrange interview 




(254) 




(16.4) 


Refused 




(258) 




(16.6) 


No Reason Given 




(120) 






Reasons Given (percent) 




(138) 






No Time 


21 








Not Interested 


19 








Work Obligations 


28 








Family Obligations 


15 








Husband Refuses 


14 








Other 


13 








DIS Case Screen 




(134) 


655 


(16.8) 


Randomization to Groups 




N 


Percent 




Controls 




199 


29.9 




El 




210 


31.5 




E2 




257 


38.6 





2 1 Latino Mental Health 



expectation that the greatest subject loss would occur in the E2, or 
Merienda intervention. This was due to participant-burden involved 
in the E2 modality which required women to travel to meeting sites. 
It was only after randomization that women were asked to partici- 
pate in a specific experimental modality. This study used a "random 
invitational design" where women were approached "cold" and 
asked to take part in an intervention study of which they had no 
knowledge until contacted at their front door by project screeners. 
They were not aware that they were in a "risk group." They were 
also unaware of the conditions for their participation until after ran- 
dom assignment. No doubt it is obvious to the reader that this aspect 
of the study was disturbing to the investigators. Unacculturated 
Mexican- Americans, after all, are well known for underutilizing 
mental health services. 

The outcome interviews were also conducted on a face-to-face ba- 
sis six months after the termination of intervention activities. The 
essential outcome analyses are summarized below; however, readers 
wishing to bypass this technical discussion can proceed directly to 
the section entitled "Summary of Intervention Effects". 

Experimental Mortality 

The effective randomized N's were as follows: Controls (C) = 
196, (Linkperson (EI) = 203, and Merienda (E2) = 254. Of the liv- 
ing subjects randomized at baseline (N = 653), 78% completed the 
outcome interview approximately one year later. Among the 22% 
(N = 146) women lost, two thirds (65%) had moved from the area 
and could not be located while the remaining third refused the out- 
come interview. No significant difference in case loss rate among the 
three modalities was found. Outcome interview completion rates by 
modality were as follows: C = 79%, El = 76%, and E2 = 78%. 
Discriminant analyses where performed to examine possible differ- 
ences between those women who were successfully reinterviewed for 
the outcome measure and those who refused or had moved out of 
the area. No combination of a large set of demographic and psy- 
chosocial variables was found to predict successful reinterview. Also, 
no significant difference was found among the reinterviewed, moved, 
and refused interview at the time of the baseline CES-D which was 
the primary outcome variable. Given these observations pointing to 
the absence of mortality bias, our intervention evaluation examines 
only that 78% subset for whom both baseline and outcome measures 
are available. 



Preventing Depression in the Hispanic Community 21 1 



Participation in the Intervention 

Under our protocol, prior to randomization, we obtained from 
every eligible subject a verbal agreement to participate in any one 
of our three modalities. Although we projected that 20% of El and 
30% of E2 could or would not follow through on this agreement, 
the actual failure rate was higher than anticipated. The intervention 
in both modalities was designed to be administered over 12 sessions. 
For presentation and analyses purposes, we converted level of par- 
ticipation into proportions to yield the following trichotomy: "0 or 
none," "0.08 to 0.49, or more but less than half dropout", and 
"0.50+ full participation." 

The data appear in Table 2 where it can seen that 31% of El 
women did not participate, 18% "dropped-out" (0.08-0.49), and 
51 % participated at the "full" level of one half or more of the sched- 
uled sessions. In the E2 modality, the rates were 52% with "none," 
18% "dropouts" and 30% "full" participation. Given the relatively 
large proportions of women who received little or no intervention, 
our evaluation analyses takes participation into account. 

Baseline CES-D means by modality and level of participation in 
the intervention also appear in Table 2. Among the El women, it can 
be seen that non-participants show the lowest baseline CES-D mean 
(8.0) and full participants the highest (9.9). While the differences 
are not statistically significant, they do suggest a pattern of self- 
selection whereby women with higher CES-D symptom levels are 
more likely to participate. A more pronounced and statistically sig- 
nificant pattern of baseline CES-D differences emerges in E2. Self- 
selection appears to have taken place in the E2 modality as evidenced 
by the low CES-D mean of 5.6 for women who dropped out, com- 
pared to the means of 1 1 .3 in the "full" and 9.2 in the "none" par- 
ticipation categories. Unquestionably, self-selection poses a serious 
problem for the evaluation and makes it apparent that its potential 
to distort outcomes must be taken into account. The fact that par- 
ticipation level is associated with the baseline CES-D score requires 
that comparisons, which examine only participating women, make 
adjustments to render them more comparable to controls. 

Given self-selection into intervention participation on the base- 
line level of CES-D, extensive analyses were performed in an effort 
to find other predictors of participation. As it turned out, no sig- 
nificant predictors emerged for El participation and only very few 
for E2. The profile of "full" participation in the E2 modality sug- 
gests that these women were younger, less acculturated, and more 



2 1 2 Latino Mental Health 



Table 2. Participation by Modality and Baseline CES-D 


Modality 


None 


.08-.49 


.50 + 


Total 


El percent 

number 

Baseline CES-D 

E2 percent 

number 

Baseline CES-D 


31 

(63) 

8.0 

52 

(133) 

9.2 


18 

(37) 

9.1 

18 

(46) 

5.6 


51 

(103) 
9.9 
30 

(75) 
11.3 


100 

(203) 

9.2 

100 

(254) 

9.2 


Control 

number 
Baseline CES-D 


- 


- 


- 


(196) 
9.5 



recent immigrants. Both discriminant analysis and multiple regres- 
sion techniques were employed in our effort to construct a multi- 
variate profile of participation in the intervention. Non-linearities 
and the fact that participation may be inherently discrete rather than 
continuous made regressions of continuous participation level on the 
predictors difficult to interpret, hence, unsatisfactory. Intuitively, 
operationalization of participation level as a continuous variable is 
problematic, inasmuch as zero participation and a dropout after one 
session are more readily viewed as nominal types rather than as 
points on a continuum. Regardless, we observed that imposition of 
a metric, although analytically appealing, was conceptually 
problematic. This being the case, discriminant analysis was employed 
in an effort to construct a multivariate profile of participation for 
the two experimental groups. 

Separate analyses in El and E2 using the "0", "0.08-0.49" and 
"0.50 + " trichotomy failed to yield two statistically significant func- 
tions, which could differentiate the three categories. This is not sur- 
prising given the dearth of participation predictors. A series of 
two-group, single function discriminant analyses were also at- 
tempted. Again, we found no set of variables which could improve 
classification on participation level significantly beyond prior prob- 
abilities. Given the large list of demographic and psychosocial vari- 
ables examined, our failure to find clear differences among full 
participants, dropouts, and no-shows, could, at least in part, be due 
to the homogeneity of our sample (i.e. , low income, age 35-50, im- 
migrant, low education, Spanish speaking, and with fairly low level 
of acculturation). 



Preventing Depression in the Hispanic Community 213 



Analyses and Results 

Our intervention was through a simple three-group, pre-post test 
randomized experimental design with no provision for level of in- 
tervention or participation. Moreover, to enter these considerations 
after the fact immediately casts the evaluation into the realm of 
quasi-experimental design. Our evaluation logic will be to advance 
from the most conservative stance to those requiring more assump- 
tions and caveats. In our most conservative analyses, we compare 
all women in El or E2, regardless of participation, to controls in 
order to determine if any intervention effect on participants is strong 
enough to "carry" non-participants. With the exception of subject 
loss due to failure to complete the outcome interview because they 
"moved" or "refused", these analyses will most closely approximate 
a true randomized experimental design. It should be recalled that no 
apparent bias with respect to outcome interview status was observed. 

The next less stringent analyses will examine subsets of women 
based upon their baseline CES-D score while the last and least strin- 
gent analyses will control for both baseline CES-D and level of par- 
ticipation in the intervention. The most convincing case for 
intervention effect would derive from the most conservative analyses 
which do not account for actual participation. Recalling that only 
69% of El, and 48 percent of E2, respectively, participated in one 
or more of the 12 sessions, the intervention effect must be quite 
strong for these subjects to "carry" their entire group. 

Given the possibility of outcome on baseline CES-D non-linearity, 
and the observed potential for baseline CES-D by modality interac- 
tion, our basic analytic model addresses both problems. Employing 
multiple regression, our model takes the following form: 

D 2 = b + b, (D.) + b 2 (E) + b 3 (E)(D0 + b 4 (D0 2 + b s (E) (DO 2 
where D2 represents outcome CES-D, E = modality with Controls 
always coded "0" and Experimentals 1. Our first test is of the par- 
tial slopes associated (Dl) 2 or non-linearity (b 4 and b 5 ). For simpli- 
city, the model presented anticipates outcomes since no polynomials 
of higher than second degree were found to be either significant or 
meaningful. We next test for covariate (i.e., baseline CES-D) by mo- 
dality interaction (b 3 and b 5 ) then proceed toward the appropriate 
test for intervention effect or outcome description. 

Experimental Design Outcomes 

Table 3 presents outcomes of our first most conservative tests in 
which all subjects, irrespective of level of participation for whom an 



2 1 4 Latino Mental Health 



outcome was obtained, are compared between Experimentals and 
Controls in separate analyses for El and E2. In the El outcomes, 
it can be seen that the test for non-linearity (Lines A) is non- 
significant as is the next test for linear modality by baseline inter- 
action (Lines B). Given these outcomes, our test model becomes a 
simple analysis of covariance with baseline CES-D as the linear 
covariate (lines C). The partial slope (b = - 1.73) associated with 
El modality suggests a weak (baseline CES-D adjusted) intervention 
effect in the direction of lower outcome CES-D scores for the El mo- 
dality. This slope can be read as an adjusted mean difference of 1 .73 
points between controls and El. The probability of p < 0.145 as- 
sociated with this difference does not meet the conventional level for 
statistical significance (p < 0.05). Although in the direction of a salu- 
tary intervention effect, the effect is not large enough tobe 
conclusive. 

The outcomes for the E2 modality in the lower portion of Table 
3 are more complex. The first test for non-linearity of outcome on 
baseline CES-D (Lines A) yields what we must treat as a significant 
test probability of p < 0.058. The next test (Lines B) for non-linear 
modality by baseline CES-D interaction (non-parallelism) is also sig- 
nificant (p < 0.064). These outcomes dictate separate non-linear 
equations for Controls and E2 presented on Lines C. Here, we see 
that the non-linear term for Controls is non-significant (p < 0.221) 
while that for E2 is significant (p < 0.037). Line D presents the linear 
equation for Controls. To illustrate these outcomes we present Figure 
1 which plots the fitted values deriving from the final equations for 
Control and E2 women. Here it can seen that E2 shows lower out- 
come CES-D than controls only in the lower and upper ranges of 
baseline CES-D and that they are higher than controls through the 
middle range. To further explore these outcomes, the analyses were 
repeated for only those E2 women who attended one-half or more 
of the sessions (i.e., full participants). A similar non-linear inter- 
action emerged suggesting intervention effects only among those E2 
women with lowest and highest levels on baseline CES-D. Given the 
non-linear modality by baseline interaction, a simple test and con- 
clusion about intervention effects in this modality is not possible. 
Our observation that a similar non-linear interaction obtained when 
observations were censored to include only full participants in the 
El modality, suggests analyses within ranges of baseline CES-D. 

It is important to note that 53% of our randomized subjects had 
baseline CES-D scores of 0-6, 22% obtained 7-15, and 25% achieved 



Preventing Depression in the Hispanic Community 



215 



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216 



Latino Mental Health 



Figure 1. Fitted Outcome by Baseline CES-D: Controls vs. Merienda (E2) 
35 



30 



25 



T 
C 
O20 

M 
E 

15 
C 
E 

SlO 
D 



.2^ 



10 15 20 25 

BASELINE CES-D 



30 



35 



40 



«—- MERIENDA (E2) 



CONTROLS 



16 or higher. Baseline low end Experimental versus Control differ- 
ences, therefore, will be more interpretable than the high which 
are based on relatively fewer observations. If low baseline CES-D 
differences are thought of as evidence for prevention effects, the 
high end could be construed as "treatment" effect. Recalling that 
the study sample was specifically designed as an early preventive 
intervention (i.e., to produce smaller increases in CES-D among ex- 
perimentals), it becomes apparent that our sample is not well suited 
to addressing possible treatment effects because of the relatively 
small proportion of women experiencing elevated symptom levels 
at baseline. The fact that any appear in the high range is the result 
of using a binary caseness criterion from the Diagnostic Interview 
Schedule rather than CES-D at the second stage of screening. Given 
that 16.0 + is often used as the presumed caseness score on CES-D, 



Preventing Depression in the Hispanic Community 217 



we see that 25% of women who passed the DIS screen would be 
CES-D cases. 

Quasi-Experimental Design Outcomes 

Analyses within three ranges of baseline CES-D are presented in 
Tables 4 and 5. To enhance comparability of experimentals and con- 
trols in these analyses, the baseline level of a large number of poten- 
tial covariates was introduced into each test regression analysis. The 
covariates include employment status (EMPL = not employed, 
1 = employed), age in years, number of health related events dur- 
ing previous six months (NHLTHEV), number of weekly contacts 
with friends or family of origin (CONTACT/WK), self-reported 
health status (HEALTH 1 = EXCELLENT to 4 = POOR), self- 
esteem (low = 6 to high = 20), mastery (low = 8 to high = 24), 
self-denigration (low = 5 to high = 20), years of U.S. residence and 
acculturation (low = 5 and high = 30). Given the intercorrelations 
among these variables, typically no more than one or two emerged 
as a statistically significant covariate. Only statistically significant 
covariates are included and reported in our presentation. 

The baseline CES-D controlled analyses for the El modality are 
shown in Table 4. The first regression for the El comparison con- 
trols (Equation la) is limited to those 53% of women whose base- 
line CES-D was in the 0-6 range. The partial slope associated with 
modality on Line A.l is -3.20 with a test probability 0.026. This in- 
dicates significantly lower outcome CES-D mean scores for El 
women than for Control women. Recalling that this analysis is for 
all El and Control women within the 0-6 baseline CES-D range, we 
see that the experimental effect seems strong enough for participants 
to "carry" non-participants. In the second baseline CES-D group- 
ing of 7-15 we obtain a non-significant positive slope of 3.00 
(Equation Ila), while in the third (Ilia) 16+ grouping it is also non- 
significant but negative. 

The last and least stringent analyses incorporate level of partici- 
pation in the intervention, as well as restriction to the three baseline 
CES-D groupings, and are presented in the lower portion of Table 
4. The three levels of participation are coded as dummy variables 
with controls serving as the reference category. The outcome which 
would most clearly point to a salutary intervention effect would be 
a significant difference for full participants and no difference for 
non-participants and, perhaps, dropouts. In Equation lb for the 0-6 
baseline CES-D range, negative slopes obtain for each El participa- 
tion dummy variable. The first is clearly significant (p = 0.040), the 



218 



Latino Mental Health 



Table 4. Multiple Regression Tests for Intervention Effects on Outcome 
CES-D by Three Baseline CES-D Groupings (A) Without and 
(B) With Participation Level Consideration 





Linkperson (El) Modality 






Equation 
Baseline CES-D 
N (Control, EXP) 


la* 
CES-Dl (0-6) 
(79,83) 


Ha 
CES-Dl (7-15) 
(36,35) 


Ilia 
CES-Dl (16 + ) 

(40,37) 


A.l 


Control = 0, El = 1 


-3.20 
(1.42) (.026) 


3.00 
(2.60)- 


-1.79 
(2.48)- 


A.2 


Intercept 


6.70 
(1.24) (.000) 


-0.98 
(4.28)- 


-9.77 
(5.52) (.081) 


A.3 


Covariates (p < .05) 


1.14 CES-Dl 
(0.38) (.004) 


1.08 Slfdenig 
(0.41) (.011) 


0.75 Slfdenig 
(0.34) (.031) 

6.39 Health 
(1.89) (.002) 


A.4 


R 2 (Adjusted) 


.065 


.071 


.205 




Equation 


lb 


lib 


Illb 


B.l 


Participation Level 
.50-1.0 (full =1) 


-3.39 
(1.63) (.040) 


5.24 

(3.31) (.119) 


-3.52 
(2.78)- 




.08-.49 
(Drop-Out =1) 


-4.21 
(2.41) (.083) 


-1.90 
(4.95)- 


-3.73 
(4.72)- 




0(None=l) 


-1.51 

(2.48)- 


2.28 
(3.84)- 


5.38 
(4.44)- 


B.2 


Intercept 


6.72 

(1.25) (.000) 


-1.16 
(4.35)- 


-8.46 
(5.50) (.129) 


B.3 


Covariates (p<.05) 


1.13 CES-Dl 
(0.38) (.004) 


1.10 Slfdenig 
(0.42) (.012) 


0.83 Slfdenig 
(0.34) (.017) 

5.60 Health 
(1.19) (.005) 


B.4 


R 2 (Adjusted) 


.058 


.069 


.223 



* Presentation Format: 
-3.20 = Unstandardized Partial Slope Coefficient 
(1.42) = Standard Error of Slope 
(.026) - Test B = Probability (Reported for p < .20) 



Preventing Depression in the Hispanic Community 219 



second is marginal (p = 0.083), and the third non-significant. These 
outcomes are quite consistent with a positive intervention effect for 
this 0-6 asymptomatic/low symptom CES-D subgroup. As before, 
no significant differences emerge for the 7-15 or 16+ subgroups. The 
fairly large positive slope for full participants in the 7-15 subgroup 
(Equation lib, Line B.l) suggests a possible negative effect of par- 
ticipation among these subjects. 

The same analytic strategy was employed for tests of the E2 mo- 
dality (refer to Table 5) in which significant non-linear modality on 
baseline CES-D interaction was observed. By performing our ana- 
lyses within the three baseline CES-D ranges, we eliminate both the 
non-linearity and interaction, thus providing the basis for at least 
a partial test of intervention effects. For the 0-6 baseline CES-D sub- 
group, the modality effect slope is - 2. 15 with a probability of 0. 104, 
a noteworthy but not clearly statistically significant difference. In 
Equation Ha and Ilia for the higher CES-D subgroups, the modality 
slopes are both positive; but it should be noted, quite small relative 
to their standard errors. Participation level was taken into account 
in the next set of regressions. In Equation lb the full participation 
slope is - 3.52 with a fairly strong probability of 0.069. The dropout 
and zero participant slopes are clearly non-significant. Equations lib 
and Illb again point to no significant intervention effects for women 
in the 7-15 and 16+ baseline CES-D subgroups. 

Summary of Intervention Effects 

Seventy-eight percent (78%) of the initially randomized subjects 
were successfully reinterviewed for the outcome measure approxi- 
mately one year later. Of the remaining 22%, approximately two- 
thirds had moved from the study area and one-third refused the 
outcome interview. No significant mortality differences were found 
among the three modalities and no significant predictors of reinter- 
view were found. Experimental mortality, therefore, did not appear 
to be a source of potential bias. 

Levels of participation in the intervention were somewhat lower 
than expected. In the Linkperson (EI) modality, 31% did not par- 
ticipate at all, while in the Merienda (E2) modality, this proportion 
was higher at 52%. It should be reiterated that the E2 modality re- 
quired women to leave home to attend group sessions, thus, at least 
in part, explaining the lower participation rate. The dropout rate 
(one or more but less than half of scheduled sessions) was the same 
for El and E2 at 18%. Full participation rates (one-half or more of 



220 



Latino Mental Health 



Table 5. Multiple Regression Tests for Intervention Effects on Outcome 
CES-D by Three Baseline CES-D Groupings (A) Without and 
(B) With Participation Level Consideration 







Merienda (E2) Modality 






Equation 
Baseline CES-D 
N (Control, EXP) 


la* 
CES-D 1 (0-6) 
(79,109) 


Ha 

CES-D1 (7-15) 
(36,40) 


Ilia 
CES-D1 (16 + ) 

(40,48) 


A.l 


Control = 0, E2=l 


-2.15 
(1.32) (.104) 


1.56 

(2.32)- 


1.31 

(2.48)- 


A.2 


Intercept 


19.58 
(5.56) (.001) 


10.21 
(2.20) (.000) 


24.79 
(12.48) (.050) 


A.3 


Covariates (p<.05) 


0.91 CES-D1 
(0.34) (.008) 


2.49 Nhlthev. 
(1.19) (.039) 


6.02 Health 
(1.83) (.050) 






-3.09Empl 
(1.39) (.028) 


-0.20Contact/wk 
(0.90) (.032) 


-1.46 S.esteem 
(0.58) (.014) 






-0.27 Age 
(0.13) (0.33) 






A.4 


R 2 (Adjusted) 


.082 


.084 


.175 




Equation 


lb 


lib 


nib 


B.l 


Participation Level 
.50-1.0 (Full) 


-3.52 
(1.92) (.069) 


0.20 
(3.04)- 


-2.08 
(3.02)- 




.08-.49 
(Drop-Out) 


-1.79 
(1.98)- 


2.42 
(3.69)- 


6.15 
(6.08)- 




(None) 


-1.55 
(1.60)- 


2.48 
(2.99)- 


3.89 
(3.12)- 


B.2 


Intercept 


20.48 
(5.66) (.001) 


10.29 
(2.23) (.000) 


23.68 
(12.92) (.071) 


B.3 


Covariates 


0.93 CES-D1 
(0.34) (.007) 


2.39 Nhlthev. 
(1.21) (.050) 


6.21 Health 
(1.91) (.002) 






-3.05 Empl 
(1.42) (.033) 


-0.20Contact/wk 
(0.09) (.036) 


- 1.42 S.esteem 
(0.58) (.017) 






-0.30 Age 
(0.13) (.024) 






B.4 


R 2 (Adjusted) 


.077 


.065 


.193 



* Presentation Format: 
-2.15 = Unstandardized Partial Slope Coefficient 
(1.32) = Standard Error of Slope 
(.104) = Test 15 = Probability (Reported for p < .20) 



Preventing Depression in the Hispanic Community 221 



scheduled sessions) were 51% for El and 30% for E2. Extensive ana- 
lyses of participation revealed no profile for El and suggested that 
E2 participants were younger, less acculturated, and more likely to 
be recent immigrants. Analyses did reveal that participants tended 
to be higher on baseline CES-D mean scores. Dropouts in the E2 mo- 
dality were low on baseline CES-D, while full participants quite high. 
The association between participation and CES-D presented analytic 
complexities in the form of non-linearities and baseline by modal- 
ity interactions. 

The analytic strategy employed was to proceed from a most con- 
servative posture, which did not account for participation, to quasi- 
experimental treatments. Under this conservative approach, we 
found a fairly weak, not quite significant positive intervention ef- 
fect for the El modality. The effect on participants here was almost 
strong enough to ' 'carry" non-participants and dropouts. The out- 
comes for E2 turned out to be quite complex in that a non-linear mo- 
dality by baseline interaction was observed. Examination of the data 
suggested a positive intervention effect at both extremes of baseline 
CES-D mean score distribution. 

As suggested by the most conservative analyses, analyses were per- 
formed for subgroups based upon baseline CES-D. For the lower 
half in the 0-6 baseline range, the El intervention was found to be 
clearly significant and thus pointing to a salutary prevention effect 
for asymptomatic and low symptomatic subjects. This effect was ob- 
tained without taking participation into account. No significant mo- 
dality effects were observed in the two top baseline CES-D quartiles 
(7-15 and 16 + ); a similar but somewhat weaker outcome obtained 
in the Merienda (E2) modality. 

In the least restrictive analyses in which both baseline CES-D and 
level of participation were taken into account, it was observed that 
full participation was, in fact, associated with a prevention effect for 
asymptomatic and low symptom (0-6) women. These low symptom 
and asymptomatic women actually constituted the majority of sub- 
jects in the study because of the two-stage screening process before 
randomization. No significant effects in either modality were ob- 
served for higher baseline CES-D subgroups. 

Discussion and Implications 

Projecto Bienestar seems to have succeeded in accomplishing its 
primary goal; e.g., preventing onset of depressive symptoms among 
those women who were asymptomatic or minimally symptomatic at 



222 Latino Mental Health 



baseline. These effects held for both Linkperson (EI) and Merienda 
(E2) intervention modalities. However, the interventions were not 
effective in lowering symptoms levels among women who were al- 
ready experiencing moderate symptom levels at baseline. This indi- 
cates that the intervention is probably too weak to have significant 
treatment effects, nor was the curriculum designed for remediation 
of persistent depression. Our interpretation is that women who were 
asymptomatic (or nearly so) at baseline already have coping 
resources which are fairly effective, and the Projecto Bienestar in- 
tervention process refined and supplemented these. The women who 
benefitted from the intervention were already somewhat resilient, 
and the intervention worked to extend (or perhaps make more ex- 
plicit) their sense of personal efficacy for dealing with problems in 
daily living. In some instances, the intervention probably supplied 
emotional support, as well, which may have been in short supply in 
their lives. 

Therefore, Projecto Bienestar may not be a good general purpose 
intervention although it seems to benefit a certain subset of women 
who are appropriate for early preventive interventions. Frankly, the 
Projecto Bienestar 12-week intervention period is not long enough 
for dealing with the much more complex problem of arresting or 
reducing symptoms levels among individuals with chronic depres- 
sion. Furthermore, it would be difficult to design a low-power in- 
tervention that could meet the needs of asymptomatic as well as 
highly symptomatic women simultaneously. A paradox of this in- 
tervention is that depressed women, who were the most eager to par- 
ticipate in Projecto Bienestar interventions, were also least likely to 
be benefitted by it. 

It should be kept in mind when reviewing the results of this ex- 
perimental community trial that there is a big difference between a 
scientific study of this sort and the implementation of prevention 
programs in the community that do not require such stringent evalu- 
ation criteria. Obviously, this was a very difficult study to conduct 
and most of the logistical problems were directly linked to maintain- 
ing a strict experimental design. For example, our method of sub- 
ject recruitment was intended to produce a sample that maximized 
the generalizability (external validity) of the results. However, there 
are certainly much easier ways to conduct this process within the 
context of community natural networks or via community agency 
outreach programs. Community interventions such as Projecto 
Bienestar need to be tailored to the naturally occurring cultural prac- 



Preventing Depression in the Hispanic Community 223 



tices and life styles of Hispanics. This presupposes that intervenors 
(1) possess sufficient knowledge of local cultural customs and con- 
ditions, (2) have the ability to enter the community and access micro 
networks, (3) enjoy the programmatic flexibility to shape interven- 
tions according to the flow of daily live activity in these communi- 
ties, and (4) sustain these interventions over time. 

The best method for learning how best to conduct interventions 
in the Hispanic community is through the actual experience of do- 
ing them, and it is unfortunate that requisite resources are not made 
available for general experimentation or replication of studies such 
as Projecto Bienestar from local funding sources. Even more dis- 
tressing is the lack of linkage between research and development at 
the NIMH, which supported Projecto Bienestar, and the commu- 
nity mental health systems at the state level. Simply put, there is no 
policy or administrative mechanism available to motivate individual 
states to undertake systematic interventions of this sort once they 
have been developed and evaluated. In the absence of this linkage, 
experiments such as Projecto Bienestar will remain isolated ex- 
periences. The inhospitable climate in the arena of mental health 
prevention stands in stark contradiction to the emphasis on wellness 
and health promotion that has gained prominence nationally (Klein- 
man, 1988). Indeed, without a comprehensive prevention strategy, 
there is little that we can begin to address the spectrum of mental 
health needs found in Hispanic communities. 



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Illinois: University of Chicago Press. 



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Goldberg, L. and Breznitz, S. (Eds). (1982). Handbook of stress. New 
York: Free Press. 

Gore, S. (1969). The effect of social support in moderating the health con- 
sequences of unemployment. Journal of Health and Social Behavior, 12, 
200-210. 

Kleinman, A. (1988). Re-thinking psychiatry. New York: Free Press. 

Lazarus, R.S. (1966). Psychological stress and the coping process. New 
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Pearlin, L.I. and Schooler, C. (1978). The structure of coping. Journal of 
Health and Social Behavior, 19, 2-21. 

Presidential Commission on Mental Health. (15 February 1978). Report 
of the task panel on prevention (1822-1863). Washington, D.C.: U.S. 
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Public Law (979-35) (13 August 1981). Omnibus budget Reconciliation Act 
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ment Printing Office. 

Radloff, L.S. (1977). The CES-D scale. A self-report depression scale for 
research in the general population. Applied Psychological Measurement, 
1, 385-401. 

Robins, L.; Helzer, J.; Croughan, J. and Ratcliff, K.S. (1981). National 
Institute of Mental Health Diagnostic Interview Schedule: Its history, 
characteristics, and validity. Archives of General Psychiatry, 36, 
381-401. 

Rodgers, E.S. (1962). Man, ecology, and the control of disease. Public 
Health Reports, 77, 755-762. 

Roskins, M. (1982). Coping with life changes: A preventive social work ap- 
proach. American Journal of Community Psychology, 10, 331-340. 

Selye, H. (1956). The stress of life. New York: McGraw-Hill. 

Sorle, L.; Langer, T.S.; Michael, S.T.; Opler, M.D. and Rennie, T.C. 
(1962). Mental health in the metropolis: The midtown Manhattan study 
(Vol. 1). New York: McGraw-Hill. 

Valle, J.R. and Mendoza, L. (1978). The elder Latino . San Diego, Califor- 
nia: Campanile Press. 

Valle, J.R. (1985). Hispanic social networks and prevention. In R.L. 
Hough, P. A. Gongola and S.E. Goldston. (Eds.). Psychiatric epidemi- 
ology and prevention: The possibilities, (131-157). Los Angeles: Univer- 
sity of California Neuropsychiatric Institute. 

Vega, W.A.; Warheit, G.; Buhl-Auth, J. and Meinhardt, K. (1984). The 
prevalence of depressive symptoms among Mexican-Americans and An- 
glos. American Journal of Epidemiology, 120, 592-607. 



Preventing Depression in the Hispanic Community 225 



Vega, W.A.; Warheit, G. and Palacio, R. (1985). Psychiatric symptoma- 
tology among Mexican-American farmworkers. Social Science and 
Medicine, 20, 39-45. 

Vega, W.A.; Valle, J.R.; Kolody, B. and Hough, R. (1987). The Hispanic 
social network prevention intervention study: A community-based ran- 
domized trial. In R.E.Munoz, (Ed), Depression prevention (217-234). 
New York: Hemisphere. 

Vega, W.A. and Murphy J.W. (1990). Culture and the restructuring of 
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Wagenfeld, M.O.; Levenson, P. and Justice, B. (Eds). (1982). Public men- 
tal health. Beverly Hills, California: Sage. 



Psychiatric Treatment of 
Mexican Americans: A Review 

Cervando Martinez, Jr., M.D. 



Introduction 

There have been two notable attempts to delineate treatment 
research needs for Hispanics by Rogler et al. (1989) and Padilla and 
Lindholm (1984). Padilla, in his usual cogent fashion, reduced the 
problem to the basic issue of how to provide required mental health 
services to a growing U.S. Hispanic population and how to do 
so in Spanish (Padilla, 1984). There is no recent work, to my 
knowledge, refuting the earlier report about the significant paucity 
of Hispanic mental health professionals (Olmedo, 1977). Since that 
publication, the high rate of migration of Hispanics to the U.S. has 
not diminished, and the rate of production of Hispanic mental health 
professionals certainly has not accelerated. 

Rogler et al. (1989) describe the research challenge as one designed 
to further our understanding of what has commonly been called cul- 
turally sensitive treatment modalities, particularly psychotherapeutic 
ones. The authors pose two more specific questions: (1) Should these 
culturally sensitive treatment modalities have an "isomorphic" or 
mirror-like relationship to the client's culture? or (2) Should cultu- 
rally sensitive therapy depart from this isomorphic status and instead 
serve to bridge a gap between the client's native culture and the 
majority culture? 

Rogler et al. go on to point out that there is a very limited amount 
of research addressing these questions. In fact, as the best example 
of a research study in this area, Rogler et al. summarize Constan- 
tino's work using cuento or folk tale therapy with Puerto Rican chil- 
dren. It was found that children who received the adapted (or 
bridging) folk tale therapy had less trait anxiety than children in both 
the traditional group and the non-adapted folk tale therapy group. 
The implication of this study is that culturally sensitive therapy, that 
is directed at helping a member of an ethnic minority adapt or bridge 
to the dominant culture, may be more useful than more "tradi- 
tional" culturally sensitive therapy, at least in reducing anxiety. It 



228 Latino Mental Health 



is not clear, however, whether or not the source of this anxiety was 
cultural dissonance experienced by the children growing up in New 
York, or the result of a multitude of other factors which might also 
produce anxiety including biological ones. Finally, the relevance of 
this interesting study of children to adult disorders is not at all clear. 
It is certainly true, as Rogler et al. (1989) point out, that anxiety is 
one of the more common presenting complaints in community men- 
tal health clinics. In this clinical context, however, anxiety is a very 
non-specific symptom, and its relationship to earlier childhood anxi- 
ety is also not clear. 

Individual Psychotherapy 

The review by Rogler et al. (1989) briefly discusses the work of 
other investigators and clinicians who have attempted to address the 
question of culturally sensitive individual psychotherapy. Central to 
the discussion by Rogler et al. (1989) is the long-standing issue about 
whether poor people can benefit from psychotherapy. This point 
should be discussed further. 

Historically, the discussion has centered around the notion that 
the poor have too many real life hassles to have the patience, time, 
and interest for "insight" psychotherapy. Emotional or mental dis- 
orders are considered to be caused by social conditions associated 
with poverty, and the poor are seen as victims. This one dimensional 
view of the poor as victims of their environment appears to demean 
the poor by suggesting that they do not have rich (albeit perhaps 
traumatic) developmental and interpersonal experiences. It is con- 
cluded that their therapy should merely provide them, if at all pos- 
sible, with social assistance, emotional support, etc. Furthermore, 
psychotherapy is equated with psychoanalysis and thus dismissed as 
irrelevant. There are several problems with this argument. Not all 
Hispanics are hassled or poor. If they are poor, this certainly does 
not mean that they are free of interpersonal or developmental 
problems for which they want professional help. Many workers have 
noted this and recommended specific approaches within a dynami- 
cally oriented psychotherapeutic approach (Bluestone & Vela, 1982; 
de Monteflores, 1986; Acosta et al., 1982). 

Nonetheless, the review by Rogler et al. (1989) of the culturally 
specific modifications in psychotherapy is a valuable one. It discusses 
a number of different techniques in the isomorphic category that, 
in different ways acknowledge, accommodate, and mirror cultural 
aspects (Gomez, 1983; Pitta, 1978; Maldonado-Sierra & Trent, 1960; 



Psychiatric Treatment of Mexican-Americans 229 



Szapocznik & Fernandez, 1978). Techniques that depart from this 
isomorphic approach are also mentioned, most notably Szapocznik's 
later work (Szapocznik & Fernandez, 1980) with Cuban families and 
individuals and Boulette's (1976) assertiveness training approach. 
These techniques identify and, in some cases, reinforce cultural 
facets. In addition, they also proceed beyond this to identify 
maladaptive, perhaps culturally determined processes, such as lack 
of assertiveness in women and enmeshment in families. Some of the 
therapy is subsequently directed at attempting to modify these 
maladaptive, culturally determined elements. 

The Constantino study discussed previously by Rogler et al. (1989) 
involving cuento therapy for children is apparently the only study 
extant comparing the therapeutic efficacy of an isomorphic versus 
a non-isomorphic approach. The shortcomings and relevance of the 
study have already been discussed. In addition, the program was a 
group-mediated one involving the participation of children and 
mothers for 20 weekly, 90-minute therapy sessions. The complex- 
ity of the study, it seems, makes it difficult to determine with assur- 
ance what factors actually produced the change in anxiety. 

Only a few reductionists would argue that individual psychothe- 
rapy is of no benefit to Hispanics. Also, it appears that in some cases 
culturally sensitive modifications can be made that enhance, enrich 
or expand the effect of whatever therapy is being employed. It is still 
open to question whether these culturally sensitive modifications of 
individual therapy techniques should be isomorphic or bridging as 
defined by Rogler et al. (1989). This also depends upon whether one 
accepts Rogler's model as valid. 

Furthermore, the admonition by Sue and Zane (1987) with respect 
to the application of culturally sensitive techniques must be kept in 
mind. The authors assert that a culturally sensitive technique (just 
like any other technique in psychotherapy) can be misplaced, mis- 
directed or inappropriate. Finally, the work of Szapocznik and Fer- 
nandez (1978, 1980) has taught us that Hispanic cultural traits may 
be maladaptive, as well as adaptive, in the United States and that 
the mature clinician should acknowledge this and implement the ap- 
propriate technique to attempt to change such processes. 

Assuming that individual psychotherapy is considered a valid mo- 
dality for Hispanics, are there reasons to believe that one approach 
might be more beneficial than another? For example, it could be con- 
sidered that a behavioral approach that focuses on the solution of 
here and now problems might be more appropriate than an insight 



230 Latino Mental Health 



oriented one that focuses on developmental issues. Also, an inter- 
personal approach may be considered in Hispanics because of the 
importance of family and interpersonal relations (personalismd). 
Comparative efficacy studies of psychotherapy techniques in 
Hispanics have not been done, although the individual modalities, 
particularly behavioral and cognitive approaches, have been shown 
to have efficacy in Hispanics (Comaz-Diaz, 1981). Further research 
may not be productive in attempting to determine which specific 
techniques in psychotherapy are more effective among Hispanics. 
Psychotherapy research is laden with difficulties. In actual practice, 
it is doubtful that sensible clinicians can maintain such purity of ap- 
proaches. Rather, what undoubtedly occurs is that techniques are 
used depending on training, clinical situation and other factors. 
Finally, as Lopez and Hernandez (1987) have shown, competent 
clinicians (at least as judged by the ones he studied) already appear 
to modify their evaluative and therapeutic expectations and ap- 
proaches when encountering Hispanic patients. 

Group Psychotherapy 

The usefulness of group psychotherapy with Hispanics has been 
recognized for a long time (Delgado, 1983; Hynes & Werbin, 1977; 
Kraidman, 1980; Normand et al., 1974; Olarte & Masnik, 1985). 
Almost all authors, that have reported successful experiences with 
this modality, also described a variety of adaptations that they have 
had to make, in order to enhance acceptance and effectiveness. These 
have included flexibility in scheduling, attention to cultural factors, 
permission to discuss practical problems, flexible use of Spanish, 
careful orientation about group therapy and others. This strong tes- 
timony to the efficacy of group psychotherapy with Hispanics has 
emerged from clinical work involving primarily lower socioeconomic 
class patients. There are no comparative descriptive reports which 
include more acculturated or middle class Hispanics. It would be of 
interest to examine what adaptations, if any, need to be made with 
this group and how culturally determined themes are manifest and 
handled. 

There is no evidence to suggest that there is any particular type 
of group therapy technique (i.e., cognitive, behavioral, dynamic) that 
is superior in working with Hispanics. Most reports have emphasized 
the surprising utility and ease of acceptance of group therapy by 
Hispanics and the modifications mentioned above. Comas-Diaz 



Psychiatric Treatment of Mexican-Americans 231 



(1981) did conduct a study of depressed Puerto Rican women assess- 
ing the efficacy of behavioral versus cognitive oriented group psy- 
chotherapy and found no differences. 

Comas-Diaz (1981) examined whether or not in group therapy 
with Hispanic women certain cultural values were expressed as a 
function of different therapeutic approaches. Two approaches, be- 
havioral and cognitive, were employed in group therapy with 
depressed Puerto Rican women recently migrated from Puerto Rico. 
Although the primary question about the relationship between cul- 
tural values and therapeutic approaches was not fully elucidated, it 
was found that in both groups certain themes tended to be discussed 
that appeared to be a reflection of specific underlying cultural values. 
These more sustained themes involved children, spouses (or lover), 
and interpersonal relationships and, according to the author, they 
appeared to reflect underlying cultural values such as mahanismo 
and personalismo. Discussions reflecting mahanismo involved the 
culturally determined role of the woman as "martyr" and "long 
suffering" character (like Mary). This observation by Comas-Diaz 
(1981) about expected gender role behavior among Hispanics has 
been made repeatedly by others and serves to remind us that, at least 
in clinical populations, this is an important consideration and com- 
mon finding. 

Interesting to note were findings that somatic concerns were hardly 
mentioned, and sex was not discussed at all in this study of content 
in group therapy by Comas-Diaz (1981). The almost total lack of dis- 
cussion of somatic symptoms can probably be reconciled with 
epidemiologic findings of high rates of somatization among 
Hispanics (Escobar, 1987) by suggesting that this population may 
be more likely than other groups to present with somatization symp- 
toms if examined cross sectionally; however, once an ongoing talk 
therapy mode is established, somatization may not be as significant 
an issue. It is also possible that since the group therapist in this study 
was a clinical psychologist and not a physician, somatic concerns 
were less likely to be expressed because the clients understood their 
therapist's limitations in this area. 

Finally, the total lack of discussion about sex (presumably even 
in passing) is worth noting. As Comas-Diaz (1981) points out, the 
Puerto Rican culture has a taboo about discussion of sex in public; 
and, since the group process was short term, insufficient time may 
have elapsed for the development of confianza (trust). Nevertheless, 



232 Latino Mental Health 



this observation concerning a reluctance by female clients to discuss 
sexual matters in a group, even with a female therapist, requires fur- 
ther attention in the behavioral science literature on Hispanics. There 
is a paucity of research or even clinical reports about sexual attitudes 
and practices among Hispanic men and women, who are heterosex- 
ual or gay. This shortcoming, in this age of AIDS and other sexu- 
ally transmitted diseases, is especially concerning. 

Family Therapy 

The richest Hispanic contribution to the state of knowledge in 
mental health has been made by Hispanic family therapists begin- 
ning with Minuchin et al. (1967) and including Szapocznik et al. 
(1989) and the excellent efforts of others (Bernal & Flores-Ortiz, 
1983; and Baptiste, 1987). It is worthwhile to note, that, this state- 
ment about the relative contribution of family therapists is true only 
if we exclude the work of other U.S. Hispanics, such as Otto Kern- 
berg, whose enormous contributions have not been specifically fo- 
cused on Hispanic populations. Building largely on Minuchin's 
structural approaches, these and other family therapists have 
described their work with Hispanic families focusing on the issues 
and the themes encountered and on the technical modifications re- 
quired. Some authors have discussed outcome; however, most of the 
reports have been theoretical and descriptive. 

Szapocznik et al. (1983; 1988; 1989) have been the most produc- 
tive in conducting and reporting Hispanic family therapy research 
with Cubans in the United States. They have examined engagement 
strategies (Szapocznik et al., 1983), conjoint versus one-person 
family therapy (Szapocznik et al., 1988) and the efficacy of struc- 
tural versus psychodynamic child therapy in boys (Szapocznik & 
Kurtines, 1989). The structural approach to family therapy with 
Hispanics has had particular appeal because of the apparent match 
between this modality and the value orientation and interpersonal 
style preference of Hispanics. This assumption is partially supported 
by Szapocznik 's finding that structural family therapy, compared 
to psychodynamic child therapy, was found to be more effective in 
protecting the integrity of the family at one year follow-up. It was 
also concluded, however, that family structural change alone was 
not the mechanism mediating symptom reduction in their individual 
subjects, given that both the structural and the psychodynamic ap- 
proaches resulted in psychodynamic shifts. 

There has been relatively little reported on psychoeducational ap- 



Psychiatric Treatment of Mexican-Americans 233 



proaches with Hispanic families of seriously mentally ill individuals. 
This area warrants further exploration since it has been reported 
that, at least among Mexican Americans, there are significant differ- 
ences in family attitudes toward a schizophrenic member (Jenkins 
et al., 1986). The manner in which these attitudes translate into be- 
havior and family function has not been sufficiently explored. 

This area of family and Hispanics is such an extensive and poten- 
tially rewarding one that it cannot be done justice in this type of over- 
view. For this reason, I would recommend that this area be pursued 
further in the form of a review by someone from the field; a com- 
missioned workshop and a monograph are some other similar 
mechanisms. 

Pharmacotherapy 

There is a very limited amount of research on pharmacotherapy 
and Hispanics, including the psychosocial aspects of medication 
usage. The latter gap is particularly distressing for several reasons. 
Somatization is generally believed to be more common among 
Hispanics, and, if this is so, it would follow that Hispanics also are 
more interested in somatic cures, i.e., medication. Studies of the per- 
ception of mental illness (Karno & Edgerton, 1969) support the view 
that some conditions are perceived by Hispanics as more medical and 
hence biologic. Thus, if there is indeed a tendency for Hispanics to 
prefer somatic cures, it is troubling that more in-depth studies have 
not been conducted about Hispanic attitudes toward medication, 
compliance patterns, side effect profiles, placebo effects, and similar 
qualities. It seems that this could be a fertile area for at least some 
preliminary descriptive studies. 

The principal impression reported is the possibility of a greater 
sensitivity of Hispanics to psychotropic drugs, in terms of clinical 
response and side effects (Marcos & Cancro, 1982). A study of 
Colombians also supported this impression (Escobar & Tuason, 
1980). Another study, however, comparing the pharmacokinetics of 
nortriptyline in normal Hispanics (Mexicans in the U.S.) and An- 
glos found no significant differences in the two groups (Gaviria & 
Javaid, 1986). The latter report concluded that, if the clinical ob- 
servation of differences in sensitivity are real, then, at least for this 
drug, the difference may be due to receptor sensitivity. This possi- 
ble receptor sensitivity difference may also be worth further in- 
vestigation. 

There are no reports, even impressionistic ones, of the clinical 



234 Latino Mental Health 



effects of antipsychotics, anxiolytics or the newer (serotonergic) anti- 
depressants in Hispanics. In this regard, a review of the Latin- 
American psychiatric and psychopharmacologic literature would be 
informative since this literature may at least contain some anecdo- 
tal or clinical reports about the drugs. 

Folk Systems 

Folk systems will not be reviewed here except to point out that it 
is well recognized that each of the three major Hispanic subgroups 
in the U.S. has its own distinct folk/religious treatment system. 
These systems have been investigated descriptively and ethnographi- 
cally. It is a matter of debate whether further research should be con- 
ducted on these systems, their practitioners and techniques, since 
almost by definitions their theoretical base and techniques lie out- 
side the realm of "scientific" investigation. Nevertheless, it is also 
generally accepted, with some modest dissent, that these approaches 
are an important source of treatment for many Hispanics, and any 
discussion of the mental health treatment of Hispanics should not 
omit them. 

The explorations by Jenkins (1988) and Guarnaccia et al. (1990) 
are especially illuminating. The latter study, in particular, defines 
the issues and concerns having to do with the role of cultural 
response styles and of culturally meaningful expressions of distress. 
Cuellar and Roberts (1984) have previously discussed this issue of 
response style but with different conclusions. 

Program Adaptation 

Ethnic group specific treatment programs have been developed in 
many regions of the country and have included several that focused 
specifically on Hispanics. Some have involved the adaptation or re- 
organization of an entire outpatient clinic (Heiman et al., 1975); 
others more commonly have consisted of separate ethnic-specific 
units in institutions (Dolgin et al., 1987; Lopez et al., 1990). Some 
of the latter, such as the Hispanic program at Saint Elizabeth's 
Hospital in Washington, D.C., have provided a day time psychiatric 
program for Hispanic patients involving Spanish-speaking person- 
nel and culturally attuned activities and treatment modalities. Others 
have involved entire 24-hour care programs. Interestingly, there are 
no studies examining the relative effectiveness of these programs 
compared to traditional, culturally neutral ones. Such studies may 






Psychiatric Treatment of Mexican-Americans 235 



be important, particularly those focusing on short term treatment 
units or day hospitals, to capitalize on the trend toward briefer hospi- 
tal stay and increasing use of day hospitals. 

Conclusions and Recommendations 

There are several areas of investigation and further activity that 
could result in productive gains. First of all, family therapy, the 
richest area of Hispanic contribution to the field, should be en- 
couraged. This could be done modestly by sponsoring regional con- 
ferences, workshops, and similar activities, perhaps in conjunction 
with the appropriate subunits of the major professional associations. 
It does appear that in a multicultural nation with increasing immigra- 
tion, the contributions of Hispanic family therapists are a com- 
modity worth nourishing. It would also be important to explore what 
therapeutic work has been attempted with the families of seriously 
mentally ill, particularly schizophrenic Hispanics. Only a few 
preliminary reports, most notably Jenkins et al. (1986) are available 
on this topic. 

Specific studies of the relative efficacy among Hispanics of the 
more recent innovative therapies may also be important. For exam- 
ple, it would be of interest to examine the efficacy of cognitive ther- 
apy versus other psychotherapy in seriously depressed Hispanics. The 
greater emphasis by NIMH on serious mental illness should be recog- 
nized, and, as much as is reasonable, Hispanic research efforts 
should probe for gaps in this knowledge. Additional studies focus- 
ing on the pharmacological aspects of antipsychotics in Hispanics 
have been mentioned as important. 

The deafening silence on sexuality in Hispanic therapy literature 
merits further exploration as discussed earlier. Strategies to enhance 
our understanding of this major area of human life in Hispanics, and 
other minority groups, should be developed. Several types of modest, 
yet useful research initiatives in sexuality, can be envisaged, such as: 
(1) sexuality studies of specific subgroups, i.e., women, gay men, 
adolescents; (2) studies, conferences and other activities focusing on 
Hispanic professionals, in order to understand and deal with their 
own issues with sexuality. (It might be assumed that Hispanic profes- 
sionals may also have culturally determined attitudes regarding sex- 
uality that affect how they deal with it in their professional work); 
and (3) risk behavior change studies utilizing culturally sensitive in- 
tervention. 



236 Latino Mental Health 



Finally, we should be mindful of Fabrega's (1990) distinction be- 
tween establishment Anglo-psychiatry and its approaches and those 
which are applicable to Hispanics and other ethnic groups. Fabrega 
cautions that what we diagnose and treat using the establishment di- 
agnostic (DSM III-R) and treatment systems may not necessarily ap- 
ply to the various Hispanic subgroups or other ethnic groups in the 
United States. Basic diagnostic definitions derived from the Anglo 
population of the U.S. may not fit with the reality of other groups. 
The same can perhaps be said about therapeutic definitions, concepts 
and their applicability. The folk conceptualization of mental illness 
and its treatment among U.S. ethnic groups may shed some light on 
this dilemma. 



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Psychiatric Treatment of Mexican-Americans 239 



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Appendix 



Commentary on 

Management of 

Public Sector 

Mental Health 

Services for Latinos 






Mental Health Research in the 

Public Sector and Its Impact 

On Hispanic Clients 

Floyd H. Martinez, Ph.D. 



The country's public mental health systems are undergoing dra- 
matic changes as a result of major shifts in public policy and con- 
sequent changes in funding strategy. At a most fundamental level, 
the philosophical underpinnings of community based mental health 
care are rapidly shifting from a belief in the right to treatment by 
all who need it to a pragmatic realization that only a select few can 
be served with the resources available. How this basic narrowing of 
the eligibility spectrum is achieved varies from state to state and from 
provider to provider, but the net effect is that vast notch groups are 
being created in the service of managed care. In order to begin to 
appreciate the need for, and impact of, community mental health 
research, an overview of this new mental health care environment 
is necessary. With some sense of how the public mental health script 
is being performed, we can hopefully be in a better position to 
examine the special case of Hispanic mental health research in the 
public sector. 

Although several factors have played a role in the current trans- 
formation of community based care, the passage of PL. 99-660 
(1986) has served to bring the basic realities uniformly to all fifty 
states. Simply stated, the law requires states to develop a systemwide 
plan which places two distinct clinical populations as exclusive pri- 
orities for the utilization of federal block grant funds: severely men- 
tally ill adults (SMI) and seriously emotionally disturbed children 
(SED). In a sense, this requirement represents the coup de grace for 
local provider systems, which have been continually stressed by: 

1 . State systems which were seriously underfunded in the face of 
continually increasing demands for services; 

2. Steeply escalating administrative costs, such as professional 
liability insurance, occupancy costs and accountability requirements; 

3. Increasing competition by the private psychiatric sector, which 
is capable of chipping off the few profitable aspects of the array of 
services; and 



244 Latino Mental Health 



4. Scarcity of human resources with adequate training and ex- 
perience to meet the credentialing requirements of payors. 

It is clear that much of the impetus for PL 99-660 came from the 
intensive criticism that community based programs, particularly 
community mental health centers (CMHC) originally created with 
National Institute of Mental Health (NIMH) support, were not serv- 
ing the "chronically" mentally ill. Among the principal critics were 
the National Alliance for the Mentally 111 (NAMI) and its state af- 
filiates around the country. It was claimed that CMHC's systema- 
tically chose to serve the "worried well" and sent the difficult cases 
to intensive settings such as the state hospital. To a substantial 
degree, the criticism was undeserved. While it is true that some 
centers actively resisted the severely mentally ill client, many more 
attempted to meet the needs of this difficult and expensive group 
with grossly inadequate fiscal resources and without a clear and co- 
herent state or federal policy. We must keep in mind that in many 
states, centers operate under a unit reimbursement contract with the 
state mental health authority. Thus, the center produces what the 
state buys. Another significant impediment for the CMHC's was the 
lack of well trained professional staff to serve the client with major 
mental illness. This lack, at least partly attributable to the failure of 
graduate training programs in the mental health disciplines, is par- 
ticularly acute with regard to professionals specifically trained to 
serve racial and ethnic minorities. 

The new era of managed mental health care is characterized by 
rapid organizational structural change and major adjustments in 
operational philosophy. With ever growing numbers of ineligible 
client groups appearing at the doors of the providers and with payors 
severely limiting rates and service packages, CMHC's and other 
specialty programs have come to the obvious conclusion that they 
must adopt a far more entrepreneurial approach, or go out of busi- 
ness. The clear pathway is toward a management strategy that cre- 
ates and seizes a range of opportunities to broaden the funding base 
and, at the same time, trims all fat from the organization. The time- 
honored mission statement cast during the community mental health 
center development era, which addressed the precept "services to all 
in need, regardless of ability to pay and without regard to race, color 
or creed", is being nostalgically placed in the archives of the Board 
of Directors. 

In its place, the modern CMHC is developing a corporate culture 
and structure designed to utilize public funds with far greater cost- 



Mental Health Research in the Public Sector 245 



efficiency and to seek new ventures in the alphabet soup of the 
broader health care arena. Thus, the CMHC, which was once proud 
of its comprehensive continuum of treatment and prevention, is giv- 
ing way to a new cluster of non-profit and profit corporations 
designed to be "leaner and meaner and faster." This new mental 
health care environment is producing a long list of important ques- 
tions. For example, what happens to quality of care in service sys- 
tems designed for cost containment? What level of training (and cost) 
is necessary to deliver a unit of service? To what degree is it possi- 
ble to substitute academic credentials with focused on the job train- 
ing? Are all the traditional academic disciplines necessary in this new 
mental health care environment? Is traditional, insight-oriented psy- 
chotherapy effective with severely mentally ill clients; and, can such 
therapeutic efforts continue to be meaningful in highly limited treat- 
ment plans? Are there well documented treatment modalities which 
consider the special needs of minority groups and are they cost- 
effective? 

It is at this point that we turn to the mental health research liter- 
ature for answers. What do we find? It is generally known that men- 
tal health services research has generally lagged behind the existing 
conditions in the applied community environment. This is mostly due 
to the fact that the "cutting edge" of community mental health has 
been largely determined by fiscal limitations, legislative/political 
considerations and judicial decision making, all of which directly im- 
pact how local governments manage service programs. These 
processes do not systematically consult the mental health research 
literature. If they did, they would be disappointed because acade- 
mically based researchers have been most interested in epidemiologic 
data, limited clinical outcome and program evaluation. A notable 
exception is the psychopharmacologic arena. 

With regard to research on minority group issues, activity has been 
woefully meager in all areas. Those few studies which have been con- 
ducted have tended to focus on minority group elaborations of 
research questions about the general population. Even in the most 
recent policy setting and research planning efforts, the minority com- 
ponent is uninspired and largely out of touch with the fundamen- 
tal direction the field is taking. In this regard, let us examine 
examples from the "national strategy" of the NIMH and the Na- 
tional Advisory Mental Health Council issued in 1991 in a report en- 
titled "Caring For People With Severe Mental Disorders: A National 
Plan of Research to Improve Services". The plan outlines three 



246 Latino Mental Health 



research strategies in dealing with rehabilitation in the section on 
"Minority and Cross-Cultural Issues" (p. 24): 

1. "Investigators should attempt to discover whether being a 
member of a minority group makes a difference either in the effec- 
tiveness of rehabilitation or in the extent of rehabilitation services 
received from the state." 

2. "More studies are needed to identify how to make service pro- 
grams culturally appropriate and sensitive. One question, for exam- 
ple, is whether minority group members are more likely to use and 
be comfortable with culturally specific mental health centers. These 
centers target a particular ethnic or racial population using staff from 
the community. Another important question is whether being of the 
same ethnic group as the therapist is particularly helpful to a 
minority client, or whether it is more important to have a 
therapist — of any ethnic group — who has been trained in multicul- 
tural competence and sensitivity. Research might also explore vary- 
ing cultural perceptions of psychotic disturbance, cultural styles of 
help-seeking, and cultural appropriateness of services." 

3. "Rehabilitation of severely mentally ill persons emphasizes the 
importance of fostering independence. Yet in many minority cul- 
tures, interdependence is highly valued. Researchers should study 
the therapeutic use of interdependence in minority cultures that value 
it. This may mean permitting family members to take an active part 
in a client's rehabilitation. Not only does this spread the burden over 
a larger network, it is also consistent with the role of families in many 
cultures throughout the world." 

While these strategies might be of some long-term, academic in- 
terest, they are substantially out of touch with the day-to-day needs 
of psychosocial rehabilitation programs for severely mentally ill 
adults from minority cultures. In the brief critique of the research 
strategies listed above, we must keep the following applicable fea- 
tures of managed care systems in mind: 

1 . Managed care is a service philosophy based on a prevention 
model; e.g., the service plan is aimed at wellness promotion and early 
intervention to reduce the cost of advanced conditions. 

2. The focus of managed care is on cost containment with some 
"negotiated" standard of care. 

3. Managed care systems depend on open market competition as 
a means of fostering low rates. 

4. Managed care is payor driven. That is, the health plan or the 



Mental Health Research in the Public Sector 247 



state mental health authority ultimately dictates what services are 
provided and at what price. 

Research efforts with minority groups are often misleading, be- 
cause some assume a level of homogeneity in the subject population 
and in the programs. For example, Hispanic clients vary widely in 
acculturation and subcultural background. In addition, considerable 
variability is introduced by the often fluid clinical picture where 
clients vary in acuity through time and across diagnostic groups, giv- 
ing rise to many interactions which are very difficult to control. 

With regard to the cultural appropriateness of programs and the 
comparative "use" of programs by mentally ill Hispanic clients, the 
availability of staff skilled in the language of the client remains as 
the single most practical aspect of cultural appropriateness. In the 
public sector, clients essentially have no choice as to what programs 
they use or how many units of service they receive. 

Involvement of the family is usually acceptable and often en- 
couraged in the rehabilitation process of severely mentally ill clients. 
The goal of rehabilitation is to foster independence, but interdepen- 
dence between and among significant others is not necessarily incom- 
patible with program goals. In reality, however, program experience 
shows that up to approximately one-third of severely mentally ill 
clients have no family to involve, or the family has deserted them 
in the turmoil of the mental illness. 

Perhaps a more useful research agenda for the public sector would 
be to focus on program and administrative issues that often make 
the real difference for minority group clients. For example, there is 
a need to examine the various attributes of the human resources in 
relation to clinical outcome. There is also a need to develop models 
for training, assessment and compensation of bilingual skills and to 
demonstrate the cost-benefit to payors. Similarly, it would be highly 
useful to compare systems of care that systematically construct staff- 
ing patterns and arrange facilities of cultural competence and pro- 
grams that do not. Clinical and cost data that showed positive 
systemic differences in favor of the first type of program, would 
make a powerful case for culturally competent systems and further 
development of services designed for cultural competence. Such a 
competitive edge could quickly have a significant effect on the 
marketplace. 



248 Latino Mental Health 



References 

National Advisory Mental Health Council (1991). Caring for People with 
Severe Mental Disorders: A National Plan of Research to Improve Ser- 
vices. Rockville, Md.: U.S. Department of Health and Human Services. 



Systems Change in 
Public Mental Health 

Sandy Padilla, M.S. 



To create long-term systems change in one of the largest mental 
health systems in the world, with 31,000 employees; in the second 
largest State in the nation with a government of 150,000 employees; 
or in a State Senate controlled by Republicans and an Assembly con- 
trolled by Democrats — research is not enough. In these times of 
diminishing Federal and State funds, we need to be strategists, diplo- 
mats, experts, negotiators, teachers and politicians. 

To assist policy makers in developing mental health models and 
programs, which are culturally relevant, effective and respectful of 
cross-cultural differences, we need valid research. This research can 
be integrated into a macro-systems approach for change. To be ef- 
fective, there must be organizational change at every level of the pub- 
lic mental health system. 

Overview 

The public mental health system in New York State is large and 
complex. The New York State Office of Mental Health (OMH) pro- 
vides direct mental health services through 31 State psychiatric 
centers with a culturally diverse workforce of approximately 31,000. 
This system is administered and regulated through five regional 
offices which monitor and license public mental health programs. 

Culturally and ethnically diverse patient populations within this 
system have traditionally experienced unique needs regarding access 
to and relevant delivery of mental health services. The standard, 
culture-bound treatment approaches have inhibited successful service 
by creating cultural, linguistic and ethnic barriers to effective men- 
tal health care. 

The large increase in minority populations in New York State, es- 
pecially in the metropolitan area of New York City, poses a challenge 
to our current system. The 1980 census showed Hispanics 
represented 18% (1,464,634) of New York City's population; and 
the 1990 census indicates 24% (1,783,511) (Summary . . . Public 



250 Latino Mental Health 



Law 94-171, 1991). Similarly, there is a large percentage of minorities 
in the Office of Mental Health (OMH) patient population. For ex- 
ample, minority patients constitute 73% of the forensic population 
and 31% of the adult patient population, and the numbers are con- 
tinually increasing. Although the client population of the OMH con- 
sists of approximately fifty percent ethnic minority persons, the 
distribution of mental health professionals by ethnicity reflects a 
paucity of ethnic minority persons (Tables 1 and 2). 

Systems Approach 

The large, complex system often has gaps in services and programs 
to address Hispanic and other minority needs. OMH has invested 
in a system-wide approach to deal with the critical issues of increas- 
ing minority patient populations and the lack of administrative, 
professional and clinical staff knowledgeable of and sensitive to the 
sociocultural needs of this patient population. 

Management and clinical staff are the important link between 
policy and implementation. They must have the multicultural 
knowledge and attitudes necessary to coordinate and integrate ef- 
fective public mental health services throughout the system. 

Changing the monoculture of an organization is a complex process 
and requires a systematic approach at all levels, including: policy/ 
management, service delivery, and human resources levels. To ac- 
complish this change, we need valid research that is not exclusively 
based on majority, middle class, white populations and investigated 
by middle class researchers. We need culturally and ethnically rele- 
vant and sensitive research, as well as psychiatric research instru- 
ments free of ethnocentrism. The interaction of valid minority 
mental health research and ongoing systems change at policy, ad- 
ministrative and clinical care levels will create the synergistic ef- 
fect necessary for a monocultural paradigm shift to a multicultural 
paradigm. 



Table 1. 


Ethnic Distributions of Mental Health Services Statewide 
(Adults, Children/ Youth, Forensic) 


Admissions White 


Black 


Hispanic 


Asian 


Native 
American 


Unknown 


Inpatient 55.5% 
Outpatient 49.1% 


29.9% 
30.4% 


11.3% 

17.4% 


1.3% 
0.8% 


0.3% 
0.4% 


1.6% 
1.9% 



System Change in Public Mental Health 



251 



Table 2. Ethnicity of New York State Office of Mental Health Officers: 
Administrators and Officials (N = 533), and Professionals 
(N = 12,222) 



September 1991 
Admin. /Officials** 




Professionals*** 




White 


79% 


White 


74% 


Black 


10% 


Black 


12% 


Hispanic 


2% 


Hispanic 


3% 


Asian 


10% 


Asian 


11% 


Native American 


.02% 


Native American 


.03% 



** Includes titles such as Commissioner, Executive Deputy Commissioner, Facility 
Directors, Director of Psychiatric Rehabilitation, Director of Staff Develop- 
ment & Training, Director of Institutional Human Resources, Director of 
Community Services, Director of Quality Assurance, Director of Facility Ad- 
ministration. 

*** Includes titles such as Psychiatrists, Clinical Physician, Nurses, Occupational 
Therapists, Rehabilitation Counselors, Social Workers, Psychologists, Treat- 
ment Team Leaders. 

Source: 
Agency workforce analysis by federal occupational category. (1991). Albany: 

New York State Department of Civil Service, Division of Affirmative Careers. 



Cultural Diversity Programs 

The Office of Mental Health has begun this paradigm shift by de- 
veloping cultural diversity programs. The New York State Office of 
Mental Health Cultural Awareness Programs include: 

A. Minority Education, Research & Training Institute. This In- 
stitute was created to expand educational, training, research and 
recruitment opportunities for minorities in the mental health field 
and to improve the quality of care for minority patient populations. 
The Institute is developing clinical training models for use in all pub- 
lic mental health programs serving minorities. 

B. Cultural Awareness Training. In 1988, the OMH initiated Cul- 
tural Awareness Training for the State psychiatric center clinical and 
direct care staff on Black and Hispanic issues related to patient care. 
Some areas covered in the training include: religion, health beliefs, 
dietary customs, language barriers, skin & hair care and the effects 
of medication on various racial groups. This training is being incor- 
porated on a statewide basis. 

C. Forensic Cultural Awareness Training Program. In 1988, the 



252 Latino Mental Health 



OMH funded the first Forensic Cultural Awareness Training pro- 
gram for forensic staff. It was developed to meet the needs of an in- 
creasing Hispanic forensic population. The Hispanic forensic 
inpatient and outpatient (admissions) population is approximately 
25% (2,038) of the current total forensic population. 

D. Spanish Immersion Training for Forensic Staff. In 1988, the 
OMH funded the first Spanish language accelerated training pro- 
gram for forensic clinicians. This training program was established 
due to the lack of Spanish-speaking staff in the forensic units and 
in rural areas of the state. This training program helps meet the need 
for Spanish-speaking staff for the growing Hispanic forensic 
population. 

E. Multicultural Advisory Committee (MAC). This Committee, 
which meets on a monthly basis, advises the Commissioner on 
policy, programs and activities regarding minority mental health 
matters. Its members make recommendations on solutions to meet 
the needs and concerns of minority patients in New York State. Their 
overall mission is to ensure equity in the service delivery system for 
the OMH's culturally and ethnically diverse patient population. The 
16-Member Committee consists of representatives from across the 
state, and it includes leading Hispanics, Blacks, Asians and Native 
Americans who are authorities in the field of mental health. The 
MAC has established statewide regional Multicultural Advisory 
Committees to assist in carrying out their goals and objectives at the 
regional/psychiatric center levels. 

The New York State Office of Mental Health offers a variety of 
bilingual and bicultural programs, including the following :the Bronx 
Psychiatric Center Bilingual/Bicultural Psychiatric Program; the Pil- 
grim Psychiatric Center Bilingual/Bicultural Ward; the Pilgrim Psy- 
chiatric Center, which provides a Day Program (La Casita) for both 
inpatients and outpatients; and the OMH's Intensive Case Manage- 
ment Program, designed to identify gaps and problems in the existing 
public mental health system. 

One interesting example of a culturally competent intervention in 
these program is described here: " *M\ a young woman from El Sal- 
vador, was admitted to the hospital with serious psychiatric symp- 
toms. As newly arrived immigrant to the U.S., 'M' had given birth 
just prior to admission as a psychiatric patient, and the child was 
placed in foster care. Morose and withdrawn, unresponsive and 
silent, 'M' was diagnosed as schizophrenic, treated accordingly, and 
placed in the inpatient Hispanic ward. 'M' was attended by mem- 
bers of the Bilingual/Bicultural Staff who spoke Spanish and could 






System Change in Public Mental Health 253 



communicate with her. Staff ascertained that, rather than 
schizophrenia, 'M' was suffering from depression brought about by 
witnessing the murder of close relatives by government authorities 
in El Salvador. Pregnancy and labor had triggered her painful reflec- 
tions to produce postpartum depression. Staff were able to provide 
'M' with the proper treatment because of their ability to communi- 
cate with her in Spanish and their understanding of the particular 
experiences a Salvadoran refugee might have experienced" (Bilin- 
gual bicultural . . . center, 1991). 

Intensive Case Management Program (I. CM.). 

This new initiative is unique because it gives Intensive Case 
Managers greater flexibility in case management and guarantees ac- 
cess to needed services for their clients. It has borrowed liberally 
from successful case management programs from around the coun- 
try and has organized them as a single, flexible program to reach out 
to thousands of people who, in the past, have been unserved or 
underserved by the public mental health system. As a mental health 
system, a major goal of the Intensive Case Management program 
is the creation of an effective partnership between the Office of Men- 
tal Health, county mental health agencies, and local service 
providers. This desirable relationship is based on a strong commit- 
ment to meeting client needs (Public Report . . . Management, 
1989). 

The Bureau of Affirmative Action/Multicultural Affairs worked 
closely with the New York State Department of Civil Service to de- 
velop an effective Affirmative Action Plan to recruit minority In- 
tensive Case Managers into our system. The OMH's I. CM. 
Affirmative Action Plan was disseminated to all appropriate New 
York State psychiatric centers and offices throughout the system. 
The Plan included: (a) an affirmative action policy, (b) implemen- 
tation procedures, and (c) a process for monitoring the Plan. The 
Bureau of Affirmative Action/Multicultural Affairs provided the 
necessary technical support to the psychiatric centers. An outstand- 
ing affirmative action effort was made possible by the united, con- 
sistent effort of all OMH Divisions. This plan has resulted in a high 
percentage of minority Intensive Case Management hires. 

National Institute of Mental Health Grant 

The Bureau of Affirmative Action/Multicultural Affairs was 
awarded a National Institute of Mental Health (NIMH) grant in late 
1989 to develop and conduct a statewide Multicultural Awareness 



254 Latino Mental Health 



Program for Policymakers. The grant established the Multicultural 
Project within the State Office of Mental Health's Bureau of Affir- 
mative Action/Multicultural Affairs. The goal of the project is to 
enhance the capacity of the State Office of Mental Health to deliver 
culturally effective and efficient public mental health services to seri- 
ously, persistently mentally ill people in New York State. 

The goals of the project are being accomplished by developing and 
initiating multicultural training programs at the policy level to cre- 
ate organizational/administrative change. These system changes 
enable the OMH to coordinate and integrate new multicultural pub- 
lic mental health service models necessary to meet the needs of a 
demographically changing client population. 

The Multicultural Awareness Program for Policymakers (MAPP) 
is designed to provide New York State's public mental health 
policymakers with knowledge deemed necessary to ensure that men- 
tal health policies, procedures and service models are culturally ap- 
propriate and effective; to foster an increasingly comprehensive 
client-centered system and a culturally competent workforce of ser- 
vice providers and managers; and to encourage policymakers' in- 
tegration of culturally relevant concepts in a manner that augments 
and enhances decision-making and improves the quality of the public 
mental health care system. 

The project is under the direction of the Office of Mental Health's 
Bureau of Affirmative Action/Multicultural Affairs in collabora- 
tion with the Human Resource Management Unit and the Bureau 
of Survey and Evaluation Research. The project is consistent with 
the overall priorities of the Office of Mental Health, and it is a posi- 
tive mechanism to institutionalize the multicultural approach to ser- 
vice delivery throughout the system at the policy, management and 
implementation levels. 

Conclusion 

As demonstrated in the OMH programs outlined above, our large 
bureaucratic system is in the process of a systems/organizational 
change. This system change can only be made successful by a com- 
bination of designated resources specifically for multicultural edu- 
cational programs. In addition, success depends on establishing 
focused, long-term multicultural mental health service goals based 
on culturally and ethnically valid research. It is critical, that, as 
researchers and policy makers, we encourage and support cultural 
competency in mental health care systems. Only through a concerted 
effort can we provide culturally competent and effective public men- 



System Change in Public Mental Health 255 



tal health services for an increasing culturally and ethnically diverse 
client population. 

This system change includes programs for recruiting minorities, 
such as the Cultural Awareness training programs, the Spanish 
Immersion program, Multicultural Advisory Committee, the Bi- 
lingual/Bicultural Mental Health programs, Intensive Case Man- 
agement Program and the Multicultural Awareness Program for 
Policymakers. It is important to note that the programs are being 
implemented to enhance the capacity of the New York State Office 
of Mental Health to deliver culturally effective, public mental health 
services to seriously and persistently mentally ill people in New 
York State. 

These benefits of this multi-dimensional approach are numerous. 
Culturally sensitive programs have emerged, and treatment orien- 
tations and modalities for diverse clients have improved. The ap- 
proach should increase universal understanding of cultural values 
and linguistic considerations and recognition that ethnic and racial 
identity are key factors for improving employee productivity and 
mental health services. 

As the approach is implemented, the public mental health system 
will improve as we become more aware of the ethnocultural iden- 
tification process and how we can utilize the process to increase the 
success of treatment outcomes. Furthermore, the increase in the 
amount of bilingual/bicultural professionals will increase the utili- 
zation level of outpatient services for minority clients. 

At the same time, as management becomes responsive to cultural 
and ethnic differences, productivity and morale will improve. The 
cultural synergy will enhance employee interactions through more 
accurate understanding and will increase the capabilities of staff, as 
they develop more effective negotiation skills. Consequently, the sys- 
tems approach will enable the cross-cultural competent manager to 
improve the communication and innovation skills necessary to 
manage a diverse workforce and to provide more effective mental 
health services. 



References 

Agency workforce analysis by federal occupational category. (1991). Al- 
bany: New York State Department of Civil Service, Division of Affir- 
mative Careers. 



256 Latino Mental Health 



Bilingual bicultural psychiatric programs at Bronx Psychiatric Center, Lin- 
coln Hospital, and Pilgrim Psychiatric Center. (1991). Bronx, New 
York: Hispanic Research Center, Fordham University. 

Inpatient, outpatient and family care activity. Mental health services. Ac- 
tivity by ethnicity, age, services, facility. (1992). Albany: New York State 
Office of Mental Health, Information Systems. 

Kessler, L.L. (1990). Managing diversity in an equal opportunity work- 
place: A primer for today's manager. Washington, D.C.: National 
Foundation for the Study of Employment Policy. 

Mental health services. (1992). Albany: New York State Office of Mental 
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